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: