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1384Balsam St E€ity of Eagan 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675 -5675 Fax: (651) 675 -5694 x L� 7 SO Applicant's Printed Name Date Received: Staff: 2012 RESIDENTIAL BUILDING PERMIT APPLICATION Use BLUE or BLACK Ink r � For Office Use Permit #: / � ` 7 Permit Fee: Date: Site Address: Unit #: Description of work: t apt GC n \sol C.J ✓t Q o(A,, A- GlAt Q , G0 V3 \ C- Construction Cost: Multi- Family Building: (YeS< / No ) Name: -cS1(� US- et'1S6v Phone: 2 -- \ Address / City / Zip: eta (J 2 VA GL A.\ S+ c :/ s i^ Applicant is: (X Owner Contractor Company: (c< (F Contact: Address: City: State: Zip: Phone: License #: Lead Certificate #: If the project is exempt from lead certification, please explain why: (see Page 3 for additional information) COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING In the last 12 months, has the City of Eagan issued a permit for a similar plan based on a master plan? Yes No If yes, date and address of master plan: Licensed Plumber: Phone: Phone: Sewer & Water Contractor: Phone: Mechanical Contractor: 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.gooherstateonecall.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 the approved plan in the case of work which requires a review and approval of plans. Exterior work authorized by a building permit issued in accordance with the Minnesota State Building Cr • - dust be completed within 180 days of permit issuance. . Applicant's Signa ure Page 1 of 3 VILLAGE OF EAGAN WATER SERVICE PERMIT 3795 Pilot Knob Road PERMIT NO.: Eagan, MN 55122 DATE: Zoning: No. of Units: Owner: Address: Site Address: Plumber: Meter No.: Connection Charge: Size: Account Deposit: Reader No.: Permit Fee: I agree to comply with the Village of Eagan Surcharge: Ordinances. Misc. Charges: Total: By r Date Paid: Date of Insp.• � 5 Insp.: VILLAGE OF EAGAN SEWER SERVICE PERMIT 3795 Pitiot Knob Rood PERMIT NO.: Eagan, MN 55122 DATE: Zoning: No. of Units: Owner: Address: Site Address: Plumber: I agree to comply with the Village of Eagan Connection Charge: Ordinances. Account Deposit: Permit Fee: Surcharge: By: Misc. Charges: Date of Insp.: Total: Insp.: Date Paid: