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2750 Hwy 134 Ib). City of Eagan 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675 -5675 Fax: (651) 675 -5694 r Use BLUE or BLACK Ink For Office Use Permit #: /00 I_ � ` Permit Fee: 06 Date Received: Staff: 2011 SEWER AND WATER REPAIR / DISCONNECT PERMIT Date: * �T Description Of Work: Street Address for Proposed Work City Sewer City Water Repair (V Disconnect ? � K-7( _, - ,lJ-ei Ociel S Fee: $55.00 Name: Phone: OWNER Address / City / Zip: Applicant is: Owner Contractor Name: Address / City / Zip: Licensed Pipelayer /\ MaMaster P Property Owner / �/ 1 // // ��� l�lc ( C Phone: (9/)^ �!'Zc -E.� 0,20 1( T C � ,, ' 55' Y Pipelayer Training Certification Card #: or Master Plumber License #: I acknowledge that the information is complete and accurate and that the work will be in conformance with the ordinances and codes of the City of Eagan and the State of MN Statutes. I understand this is not a permit J 1 my an application for a it, and work is not to start without a permi L c Applicant (Print Name) Applicant'. Sign re 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.gopherstateonecall.orq