3304 Alden Pond LaneUSEONt y
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City of Evan
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
Use BLUE or BLACK Ink
For Office Use
Permit #:
Permit Fee:
..6. cx
Date Received:
Staff:
2012 SEWER AND WATER REPAIR / DISCONNECT PERMIT
Date: 7 1(a
City Sewer
City Water f Repair
Description Of Work: R ;,z
Disconnect
Fee: $60.00
Street Address for Proposed Work 3304, /11 P,4..) C3.4..7 j") (..4
OWNER
Name: AZ-De/1J Ati ') eS Phone: 95-2 — CSr
Address/City/Zip: 33')0 14 /O i AN -)43
Applicant is:
Owner Contractor
Name:
Licensed Pipelayer
X
Master Plumber Property Owner
.5e4J(,f4'' h ne: f/_ 26Z — 2.7 /8
gr'l /zr s7
Address / City / Zip: v� / 14...t )
Pipelayer Training Certification Card #: tOne).3.7 3or 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, but only an application for a permit, and work is
not to start without a permit.
Ly -z, Herr a
Applicant (Print Name) Ap licant's Signature
CALL BEFORE YOU DIG. Call Gopher State One CaII 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.org