3456 Highlander DrRESIDENT/
OWNER
Names, GL�IL . G !. l� t r. !) Phone: /501 5 L A
Address l City 1 zip: AO 1 ' '
d L J CJ(. , !
Applicant is: Owner )(/ Contractor
TYPE OF WORK
. _/
:` A .„ ,. 4 l_./ 40 • A A �..�
Description of work.Z?JL. A
, (/( IMP I
Construction Cost: l l - ( 0 0 6 - f Multi- Family Building: (Yes ) ! No )
CONTRACTOR
Company:: ( 122 1Tl kJ r Contact LAim V4mitaizie
A V City: . a It P/ / -'
1 L.0
State: Zip: (55/ 16 Phone: ( 1— ICJ % t / 7
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License* OM/ 060 Lead Certificate it: r td' /-W — 6O `t ' —1
If the project is exempt
from lead certification, please explain why: (see Page 3 for additional information)
In the last 12 months,
_ Yes No If
Licensed Plumber:
Mechanical Contractor
Sewer & Water Contractor:
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
has the City of Eagan issued a permit for a similar plan based on at master plan?
yes, date and address of master plan: _-
Phone:
Phone:
Phone:
NOTE: Plans and supporting documents that you submit are considered to be public information. Portions of
the information may be classified as non - public if you provide specific reasons that would permit the City to
conclude that they are trade secrets.
Jun. 8. 2011 2:49PM SELA ROOFING
4 City atEta
Date:
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675 - 5694
Applicant's Printed Name
For_Otfi,U
Permit#:
Permit Fee:
Date Received:
Staff:
No. 6530 P. 32
2011 RESIDENTIAL BUILDING PERMIT APPLICATION
Site Address: �f l s E ` 51569 `-` 8 .t ni
Use BLUE or BLACK Ink
CALL BEFORE YOU DIG. Call Gopher State One Call at (651) 454 -0002 for protection against underground utility damage.
Can 45 hours before you intend to dig to receive locates of underground utilities. www.00pherstateonecall.oro
I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and Codes of the City of
Eagan; that I understand this is not a permit, but only an application for a permit, and work is not to start without a permit; that the work will be in
accordance with the approved plan in the case of work which requires a review and approval y laps.
x (54-Ln V,4AJV 1 &f=
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App icant's Signature
Page 1 cos
�' ; F . GAN WATE SE R V IC E PERM
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