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e V DoDote pla ' .�
Date of " Insp.:
M �'
r crry . EAGAN
3795 filot'>Eweb O ` : PERMIT NO.: ` e ,
Almai MN 55722
Zptiing. DATE: t
Ida. of 1 s
Ada
i: : Site
{,y r fs '11 * en.:° *:e r 7,2 ' 7 C p_ III
plumb lumber: a . IT nz el
n 1 C/C0 ;`;fit^
iae21!s
agree to 10C,.:'
o p a
vrlM� the City sf �* Connection Chortle: 112 Cie 01-) p`*
Account Deposit:
1
Permit Fee: 1 en rr1
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By Y Surcharge: 5 f") /1,
Misc. Chat
o r ... Total:
•: - , 25 G) Date Pal:
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� For Qffice Use 1
. � , C �3�t � � �
� ) � Permit#: !
C��� of �a�a� l6 � Pertnd Fee:' ��.�� �
3838 Pilot Krtt�b Road � �
rxx
Eagan AAN 55122 j Date Received: j
Phone:{651)675-5675 I �
Fax:(659)675-5894 t 5taff: i
i t
. . . . . � . . .. . �� . . . �. . . . . . . .�� � �...���J
2014 RESIDENTIAL BUILDING PERM17 APPLICATtt)N
Date:�"��'"j� Site Address: ��� / � �� � � j�'� ;P��((�4J�i ��Unft'�k
Name: L/f��f�l,�'a� Cr�¢!�j '� I t�xv.-}�?a��r t� � Phone:
Residen�{ ,c� �
{�vl(114!' Atldress I Cit�+f Zip: ,�_���}'�' /- i�"'f �
ApPlicant is: Owner ./1, Contractor
Description of work: ���'''� c��� � �'G` Y'�a�'�
��li�e of WBCIt �
eonstruction�os� j�,t�p � Mut�-Family Suilding:(Yes X /No„_�
��
Company:��t'Zs/��f G c�y'!���t'i��5 '� Cantac�: t��rvt �L��Jp�
Address:���j '�Z Z�'t�I�.f �� L�'Z !�'' City:��'�[" �l�C��,�'�
Cc�ntra�ctor �
state� zi �..5�3'j Phane:�f��`"�'Email:t�r���I,3�'zt.��s'?"�c���,/�v�'c.�u
�� ����
t,.�cer�se#_ �3 C i,S"� �13 �n e.-�=K
t.eaa certlflcat8#:/!,/�-�'°,..r l��1.i�� -1
If the projec�t is exempt#rom lead cErti#ication, piease e�tai�why: (see Page 3 for additiona!infior[nation)
GOMPLETE THtS AREA ONLY tF CQNStRUCT1NG A NEW BUtLDiN�
!n the last 12 mar�t� , tt�e City of Eaga�issued a permit for a simHar plan based on a mast+er ptan?
_Yes No If yes,date and addr f master pian:
�
Licensed Piumber. Pha�:
Mechanicai Contractor: � �
Sewer�Water-Co+�t r: Phone:
l�+d�: s,at�d�v�ot�in�ds��t�rr�#s#�at yvu svbmit are�arr�sfd�r8at to be�aubf3c ttr;�c��me��: .#�o��.of
r�f+�rma�a�m��ai+��l�ssif��at as�on��r#tli��€ycru prov�c�sp�it"r�r�scrns�rat.w�+�rfd„�e�r��,���r to .;°
canc#�de Et���he ar�e�ra�e:s�r�t�`
CALL BEFORE YDU QIG. Caii Gopher Sf�te Or�e Ca{l at(651}454-0402 for proteciion�ai�st�derground utHity damage. Ca114$hours
before you intend to dig to rec�ive locates ofanderground utitities. www.gopherstateanecall:aru
f hereby adcnowledge that th�iMo�ation is cbmpiete and ac�urate;that the work rreill be in�nformance with the ordinances and r.odes af#he�it}r of
Eagan;tha#i understand this is not a permit,hut oMy an appiication for a permit, a�d work is not ta start withaut a permit;thaf#he wark witi be in
accordance with ttte appraved ptan in'tt�case of wo�tc which r�equires a reviewand approval of ptans.
Exterior work author�ed by a building pernrit issuesi in 8ccordartce w1t#t�e MMt�sota State 'lding Code must be compie6ed within 180
days cf perntii issuance. : � _
x V' 3�'� !/1G,��. � '
�� � � - �� '
Apptican�s Printed Name " aM's Signature
Page 1 of 3