4637 1_2 Penkwe Way eIT 1F ',MAN r " NATER SliRVICE
�' i t► itee4 PeRmIT ®: / s, J
is��s _ DATE . ..
wII N of knits: 1 . unit tnitse
Orrin, Thompson Foes es
;4+ 37 Pen' aE T,/ay 1. 2 B4 J C Ridgy e III
Menz
�: 3(!S 00 Rd
.
Asia. - t : • cor cti+ Oterge; 1
Skew Amour* 10.°° gd
Pewter Permit Fee- 31 50 pd
11 apse emer 4rINr Ilte City of Sages Surcharge: 60.00 pd meter
Mac. oto+9es:
Total:
eY Dote Paid:
Detterf .-.-_— i r�p.:
swat S CE PST
ite . pMIT
Maw, ket 1111 22 r Units: t
i .
TOrI r�9 Cr—:— t
,car., L2 134 C
`.:/7/8e 2041
1 M Dept.
'; Permit Fee:
Surdxn'ge:
Ity Mist.
D
n ,
Date of (rR. `' - Total: Dote Paid:
i 14 �
h
� V.,'
i 'r t ,-- -.'.
„ '
���31 `�(a��7 � �7- �����j. �(�3� � ��-
' use BLUE or BLACK lnk
� For Office Else -------�
. �Jy , � �37� ,
�1�� O��� �Il 4
� Permit# � ��
1 °-� �p !
� � Permft Fee:, J. i
3830 Piiot Knob Road � t
Eagan AsN 55122 � Date Received: �
Phone:'(651)675-5fi75 � �
Fax:(651)675-5694 t Staff: ! �
1 �
. . . . . . . . .. . . .. ' � ����������l.
2�14 RESiDENTlAL BUfLDING PERNiiT APPLiCATlt�N
qate-�"'�a�`j c� Site Address• �6 3'% _'�l� 3� �lz, ��r Y�.j-� Cv�'`1r unr�#•
.
� Name:�f?�"t?i�� ���� �t.�:�i}�z��i t_..- �Phone:
Residen#t .,�
f�iAttl�� Address t City/Zip: l".���✓�°' /E'�j�
Appticant is: l3wner � Contractor
�ir9y � - �- --
.�
TY�e.of 1lVo�'lc ��tion of work: � �t� � � ���
Gonstruction Gast j�'r��0 � N4utti-Famity Su►lding: (Yes ,y /No
!:� �..)
Company:lV�Y�2���'�9-��"r,�'s �c taa:�.� �`���a�
'C�ntr��tar address:��'!(�r'1 Z�i�.! �� L� � �;t�,:���a'�- .{'���oli�
� p ,�� ����'��l� 1
State: Zi : .�3f t Phone: EmaiLt +r►r��Jt3v't,�'�S`7�Gc��J7����7��v —
License#_�� �.�� �/ 7�j ��c�'��-.
t.�d ce,tifcate#:rV�.�-�..r=>r rlr�3 —I
if`the project is exempt from lead cet#ification, please expiain wrhy_{see Page 3 for additionai inforrr�ation)
COAAPLETE THlS�EA ONLY!F CONSTRUCTING A�EW BUtLDiAtG
In the last 12 mo , the Ci of Ea an issued a ``-r
� tY 9 permit for a similar ptan based on a rnaster plan?
_Yes _No If yes,date and add f master plan:
Ucensed Ptuml�r: Phone:
Mechanicat Cont�actor: .
3ewer&Water Cant r: Phonec
MC?�`L: ;�and,serpp�r�in�'d_o�u�nents th�t ygu sd�rn�t.ar�e�t�rrsider�ed t�be.�u�fiic irrf4nr�t� F+c��s:of .
�. rrfi�rriia��n ma�r�ie c(�ssifiec#as r�c�rl p�blic ff yv`�provicile s�`ecl�s.reas+�ns tha��rou[tff�iermr��i+���ita
� � � ' ��� can�lt�+dte fi►a#fir�' ,�r�e tr�de s�et�e�S. � �� �
CALL B�FORE YOU D16. Call Gopher St�One Cal!at(651)45A-0002 for protection against undergrour�eitlity damage. Call#8 hours
befnre you intend to dig to receive locates of underground utilities: www aonherstateoneca8 ora
t i►ereby acknaMedge that this information is canplete and ar,�urate;that the work witl be in eonfomtance with the ord'merrces and codes of#he Gity of
Eagan; that i understand this is not a pecmit,but cmly an appficat�n far a t�rn+it, and w�k is r�ot#o start watthcnit a pertni#:that the v+rork+roill be+n
w"
aceordance whh ihe approved ptan in the case of+n�rk whict►requires a rsview and approvat of pfar�.
E�cterior woei�suthor�zsd by a building permit issueE!in aceordancs wlth the Minn�ota Stabe Ming Gode m�t be campleted w�thin 180 '
daYs of t�ermlt issuance. '
'�,c ./'
x i! '� G ., , ...--
x "
Appl�canf s Prir�ted Name . ant's Signature
;, Page 1 of 3