4641 1_2 Penkwe Way N: ' Y32 7
IffatePERMIT
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pa -
A ' {)!'ills. .11r,i .t tEt�lidQ
`� .. gr in � Thasn�stin�
:E� 4 6 Peakwe Way L2 ,B J C. Ridge III
4 1' Winne'
Y +} Cherie' v305 -Pd
r /Seems* Depot*.
I fern* Fete: Its; 00 pd
410 Shit irtee + : . 50 Qd
.: 'A 60.00 pd meter
.f s Demme Paid:
imp.: •
airy 4r/F Ft
Zoning:. No. of Units: 1 tin t
sit Add roses 4541 Pen -we T'ay L2 i ,T C TTT -
"umber: L`en eI
"/7/80 20340 100.00 re
fairs. i'► aaatplr will the Sly of &woe Connection Otago: It 25.00 P
Permit . Fee: 10 I'd
Surcharge: .50 pd
By �` Misc. Charges:
Ogre cf :----
Data Total:
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- . 4 47
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�(v!l l , �v� ( � �I7-, �l.a `�3 , ��'�3 ` l�-• , Use BL.#��or$LACK Ink
� FwOfficelfise--------- I
� �i, �n �f � j Permit#_ : '�� ` �I j
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i Permi�Fee: � �
3830 Pilot Knob Road
Eagan MN 55122 � Date Received. �
Phone:{65tj 6T5-5675 � �
Fax:{659)675-5694 ! Staff: �
I 1
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2014 RESIDENTIAL BUILDiNG PERMiT APPttCAT10N
Date:�°'��`j� Site Address:���1 "_ yLa � �!/2 ��i��-' � Unit#:
Name: ��/Tl�i��t' ��� I t�tvr��ls�i Cr- � Phone: �
Resident! �
4wner add�ess i city i zip:���t-- ��-�'
�plicant is: Owner � Contractor
Description of work: ���'�` �'�� �� l �� ����
T�Re of work �
Construction Cost: l�,d�0 Multi-Eamiiy Buiiding: (Yes�/No_�
� / a'J� �
Company;�VC'JYZ��°��i �'4c��!%i�i4�C��Ur''S '� Cor►tact 1�t� f���ri'o�%
Contra�tor ,4ddress:g�`�2 Z✓�vJ�f��� Lr,�-�� �' ciry:�J��'� �!�t�L�
.
State:�Zip: ��3'`� Phone:����"�'Emaii:t��m��1Js�'LJ�S`7��.c�Y�"�✓�4��t�Y -
License#:�C ��� �7� '���-C:��r�
i�ad Certificate#:/V�i.r'...1=r>yl1�3 -�
If the project is exempt from lead eerti�catian, please exptain why:(see Page 3 for additiona!inforrr3ation)
COMPLETE THIS AREA ON�Y 1F CONSTRUCT'fNG A NEW BUILDING '
In the last 12 mont , t!�Ctty of Eagan iss�d a pertnit#or a similar plan based orr a master pfan7
Yes No )f yes, date and add f master pian:
ttcensed Ptumber: Phone:
Mechanica!Contractor: -
Sewer�Water Gont r: Phone:
,�"F�: °s an;tl su�pc�cfing dQCUmer��s fha#you sr�bmif are cor�sider+ed tv tze public infctrm��:, Pa�#i�ns of
r�rfe�ra�atior�rnay#�e�la��r#as r►c��tr pubii�if yc�u pror�de sp�i���iearsr�rts th�f wau/d pe�mit"tl��e"��!
' : c�clud+��tta�t�e" �ne�-ad�,seccei�
� GA�L BEFORE YOU D1G. Ca�t � � � , � � ���� �� � � I
Gopher Stat�One Caii at(651�45�F-0002 for proieciion against underground uflin+damage. CaU 48 hours
t�efore you intend to dig to receive locates of undergrourrci utilities. wvvw:oonherstateonecali.ora
i heret�y acknaMecige that this ir�formation is c�mmplete and acq�te;#hat the vuork wili be in tt�nfamarace with the ordinarwes aral codes of#he-Gity of
Eagan;fhat I uncterstand this is not a permit,but anly an appiication for a permit, and work is�t to start withou#a psrtn�t;that the work wili be fi'
a�ance with the approved plan in the case of vNOrtc which requires a review and�pproval of plans.
Eute�ior work authorized by a buildlr�g petmit issued Fn accorc�nce with th�R1Itlnesota Stabe iiding Gate m�t be complebed witMin 180
days csf pQmait issuance.
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Appiicanf's Printect Mame anYs Signature
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