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I For Office Use I
I I
City ~a aPermit of 66 ~
I Permit Fee: -
3830 Pilot Knob Road I I
Eagan MN 55122 Date Received: 3
Phone: (651) 675-5675 I I
Fax: (651) 675-5694 I Staff: _
----------------1
2013 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: Site Address: c r Unit
Name: tZWWWPR ~v IS6
)~l / /;Mhone:
Resident/
Owner Address / City / Zip: IWA ITAej d vel 6k atj
Applicant is: Owner _X Contractor
Type of Work Description of work: FG roe,
/ 00
Construction Cost: ~,000 ` Multi-Family Building: (Yes No
Company: / Jo, 6 A *,,c
Contact: le o gr,
Contractor Address: 00
/ V' 33
v
State: Zi : 63~
p Phone: (D
License Sc 63 16363 - Lead Certificate
If the project is exempt from lead certification, please explain why: (see Page 3 for additional information)
I
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 N
11 _ _ o If yes, date and address of master plan:
I Licensed Plumber:
I Phone:
I
Mechanical Contractor: Phone:
Sewer &
i Water Contractor:____ Phone: i
NOTE: --Plans and supporting documents that you submit are considered to be public inform-ation. Portions of
{ the information may be classified as non-public if you provide specific reasons that would permit the City to
i conclude that they are trade secrets. i
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. wviw.gopherstateonecall ora
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 Code must be completed within 180
days of permit issuance.
x/`d c k6 d xG~
Applicant's Printed Name Applicant's Signature
Page 1 of 3