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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