3481 Greenwood Ct SAug, 1, 2012 12:36PM Sela Accounting
Date:
City of Eagan
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (661) 676-5694
Address: _ .; �� erlvJp CA- . S
No.1661 P, 9
Use BLUE or BLACK Ink
For Office Use
Permitil:
Permit Fee: c-7-774,
,
Date Received:
Staff:
2012 RESIDENTIAL BUILDING PERMIT APPLICATION
Lf�7/ 4.<1°</' 0
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1 Z Site
Unit #:
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RESIDENT /
OWNER
Name: c‘ 11, •tet S rclii. �'iA ` (7)C. Phone: r•15t,q3I-11-3 j
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Address/City/Zip: (Q/j 3'3' Li' 1C.1rK l LA -)&S+- MN\'r-- 1—(\!-:At'_ r -
L�.:ll�/
i -der. PickvA�_ ,mi-) , 5 ;SIV
Applicant Is: Owner Contractor
TYPE OF WORK
Description of work: re 'coo
Construction Cost: Ids 0C) S . 00 Multi -Family l3uilddiing: (Yes X / No _)
CONTRACTOR
Company: �� c- CL-' IRO �l rt (4 d. Reit ibar-111 Contact: Kc —t 11
Address:1-1100 t .xC�-1 St o t'' �� v (I- City: St LL 1-'. 3 nil t—k
State: On Y\ Zip: 5 5'4 1 (.o Phone: CI 6)--q 1 5 -- -7 c)- C
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License#: a I2 DO 1 0 5 0 Lead Certificate #: AIA T— 5 ()3 l/ — I
If the project is exempt from lead certification, please explain why: (see Page 3 for additional information)
In the last 12 months,
Yes If
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
has the City of Eagan Issued a permit for a similar plan based on a master plan?
yes, date and address of master plan:
_,No
Licensed Plumber: Phone:
Mechanical Contractor
Sewer & Water Contractor:
Phone:
Phone:
NOTE: Plans and supporting documents that you submit are considered to be public Information. Portions of
the information may be classified as non-public if you provide specific reasons that would permit the City to
conclude that they are trade secrets,
CALL BEFORE YOU DIG. Call Gopher State One Call at (651) 4540002 for protection against underground utility damage. Cali 48 hours
before you Intend to dig to receive locates of underground utilities, www_gopherstaleonecall.orq
( hereby acknowledge that this information Is complete and accurate; that the work will be in conformance with the ordinances end codes of the City of
Eagan; that 1 understand this is not a permit, but only an appllcallon (or a permit, and work is not lo start without a permit; that the work will be in
accordance with the approved plan In the case of work whloh 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.
rthrt�,�'r
Applicant's Printed Name
Applicant's Signature /
)-91G�--1]r�-lam
Pagel of 3
CityofEaall
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
Use BLUE or BLACK Ink
For Office Use
Permit #:
Permit Fee:
ca -7 I
�
Date Received: 5 5
Staff:
J
INFLOW lFILTRATION PERMIT APPLICATION
Plumbing / Sewer & Water
6-4— /3 wm . nG ah ss12Date: Site Address: rcah
FAX
Tenant:
Description
Suite #:
Name: 7 h,1 I /4. F OY Phone: 6/5(6
Address / City / Zip: (IV l "r /-4")eh 1^f G a (�( SS72�
Name: License #:
Address: City:
State: Zip: Phone:
Contact: Email:
PLUMBING (Within the building envelope) SEWER & WATER (Outside the building envelope)
Sump Pump Repair (� Repair
Other: Beq Ltr' t.ma frf (\thoL4f Other:
Description of work: \ &%'1CLP, Lea if tr bc,Q I-)
lour b-ct
o d °est{ 1.
FEES
$60.00 / Each (includes $5.00 State Surcharge)
TOTAL FEE $
*Permit fees will NOT be reimbursed by the City of Eagan. If you plan to submit I/1 repair costs for
reimbursement, two quotes from qualified contractors must accompany this application. A list of contractors
can be found by visiting www.citvofeaqan.com/inflow, or City Hall at 3830 Pilot Knob Rd.
CALL BEFORE YOU DIG. Call Gopher State One Cali at (651) 454-0002 for protection against underground utility damage. Call
48 hours before you intend to dig to receive locates of underground utilities. www.gopherstateonecall.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.
x
Applicants Printed Name
x
Applicant's Signature
FOR OFFICE': U
wired inspections: ;Under Ground