4101 Countryview DrRESIDENT / OWNER
Name: (,fl)7_
41
Phone: n1 — �"l ►-R
Address / City / Zip: L4 I D IAU 4- t-Q,(» Y () Y
CONTRACTOR
Name: L ILL.
License
City:
#: D 5 SO 4 ,
Address: 3DO f
11 t
State: , A_ A Zip: 3 Phone:C3 �! —.. l,� i `✓
Contact: # ;� �. f • /, 1 /.e mail: j L
„ / It( hlW & 1
TYPE OF WORK
PERMIT TYPE
N e w Replacement
& .(
Additional
Aeration 11 Demolition
Description of work:
RESIDENTIAL
Furnace
t.&
A 21.
,,1
O1 Qt.. CNC& ker=4
'
New Construction
COMMERCIAL
Tank
Inspector
$ R`�
Interior Improvement
Air Conditioner
Install Piping
Processed
Air Exchanger
Gas
Exterior HVAC Unit
Heat P p
Under / Above ground
( Install / _ Remove)
�p
Other C .X.., J
** When installing/removing
Marshal and Plumbing
tank(s), call for inspection by Fire
RESIDENTIAL FEES:
$55.00 Minimum Add -on
or alteration to an existing unit (includes $5.00 State Surcharge)
burned out appliances, ductwork, etc.) (includes $5.00 State Surcharge)
C
$ --� ' TOTAL FEE
$95.00 Fire repair (replace
COMMERCIAL FEES:
$75.00 Underground tank
$55.00 Minimum (includes
installation /removal OR Contract Value
State Surcharge)
=
$10,010, surcharge is $ 5.00
surcharge increases by $.50 for each $1,000 Permit Fee =
Fee requires a $ 5.50 surcharge)
=
$ x 1%
$ Permit Fee
- If the Permit Fee is less than
$ Surcharge
- If the Permit Fee is > $10,010,
(i.e. a $10,010 - $11,010 Permit
$ TOTAL FEE
Date:
Tenant:
City of Eau
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675 -5675
Fax: (651) 675 -5694
nsko. 1\AutVe,4
CALL BEFORE YOU DIG. Call Gopher State One Call at (651) 454 -0002 for protection against underground utility damage. Call 48 hours
before you intend to dig to receive locates of underground utilities. www.Aopherstateonecall.orq
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 t - - pproved plan in the case of work whic requires a review and approval o
Appli ' ts 'rin
ame
RECEIVED
JUL 0 5 2011
Use BLUE or BLACK Ink
Permit #:
6 11e/
Permit Fee: ,6•
Date Received:
Staff:
2011 MECHANICAL PERMIT IT APPLICATION
Site Address: 4101 , ` V1 �/ e ck) 0Y
Suite #:
Applicant's Signature
J