2750 Hwy 134 Ib). City of Eagan
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675 -5675
Fax: (651) 675 -5694
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Use BLUE or BLACK Ink
For Office Use
Permit #: /00 I_
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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
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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
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Applicant (Print Name) Applicant'. Sign
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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