4553 Scott Tr :. �,� ►►�, *Alin SERVICE
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crrr OF swami SEWER SERVICE PERMIT
117121.1Pilet K+t Reed PERMIT NO.: r �.
illegsn, MN 55122 DATE: I ; L 1: ,
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Use BLUE or BLACK Ink
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I For Office Use �
' � Permit#: C/� ���N j
Clty of �a��� � �� �
� Permit Fee: �
3830 Pilot Knob Road � �
Eagan MN 55122 � Date Received: �
Phone: (651)675-5675 I I
Fax:(651)675-5694 i Staff: i
2013 RESIDENTIAL BUILDIN PERMIT APPLICATION
Date: � � � Site Address: ���` '� ��;�11 {�-A�L-� Unit#:
- Name: � � ] 1 Phone� y"�/t�
Res�denti .�.: �� �
� �`�'��Ouvner � ���� address i c�ry i zip: � �
Applicant is: Owner Contractor
; Description of work: �
Type of Work
_: Construction Co� `� �� Multi-Family Building:(Yes,�/No )
°` Compan � ��1 °' L�� . Contacte� � ��
Contractor ; Address: � ��� L..o�C��'!.� .��C City:
� �
' State:� �S Zip. Phone: �
License#:���T'���/� Lead Certificate#:
If the project is exempt from lead certification, please explain why: (see Page 3 for additional information)
' COMPLETE THIS AREA ONLY IE 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 _No If yes,date and address of master plan:
Licensed Plumber: Phone:
Mechanical Contractor: Phone:
Sewer&Water Contractor: Phone:
NOTE:P/ans antl supporting documents fihat you submit are consitleretl to be publ�c infQrma#ion Portions of ::
the information►rray be classi�ed as non-public if you provide spec��c reasans,that would p;ermit the City fo`
`, conclutle,that they.are tratle.secrets. � «
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. vwvw.qopherstateonecall.orq
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. ,
I
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. I
��. , �/ '
x� �l�iv�kS '1 i���� X ,
ApplicanYs Printed Name ApplicanYs Signa r
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