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Use BLUE or BLACK Ink
For office use l
Pennrt 0. ~ I
' I P 1 Of Eivan I
Pemnt Pea. 1
3830 Pilot Knob Road
Eagan MN $5122 i Date Received:
Phone: (651) 675$678 I
Fax: (661) 676.6684
I I
2013 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: -5 --,Z7,4/ ~ a- y; s-41 , s r, (.1 o; b A, t. Y,
Site Address:1 Yw., by. 7 0, 7A, 7q, 7 ScurHPe ~a 7`~ .T. 2~ Unit: P
Name: c c 19 C T /r1 A,J 4 l0 4 M L s,) , Phone. 743 -.r9i 3 5 7 70
~
Ovtmer . address I city i zip: 8so kS e~ o+ ~u Q Av ~ ,2 A aotD S•.! vos-t cs-y
Applicant is: Owner X_ Contractor
TypR+e. f1E c• Description of work: '7'-'.+h2 OP l- (Z E - Qvo ~
onstruc Lion cost 3 1.7 .5. X h
. Multi-Family Building: (Yes_ I tJo.~
Company: 1 £a~ r~e.lt~aR N47,i r . [.errZ>D Contact: trav,~ I~v R_R r 5
Address: Yo s- W 6 7 T. City: M p4. $
State. /19a' Zip:.~~'// 9 Phone: ~O x y3
License 0: 4d e- .1 III/ / Lead Certificate
If the project is exempt from lead certification, please explain why: (see Page 3 for additional information)
~~Aios I.J~e>r I~,,,cT Pas; i 9~ s'
COMPLETE THIS AREA ONLY IF 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?
_Yss _No If yes, dots and address of master plan:
Licensed Plumber: Phone:
Mechanical Contractor Phone:
Sewer S Water Contractor: Phone:
O t) . Call GaPherst~ Ons Call st (661) 461-0002 for protecWn againA underground udlky damage. C40 48 hours
bafm you intend to dig to rtiOelVa locates of underground Lfiftes. ! aoohersts ll or g
I h@mby acknowledge that this information Is COmplete and acudrate; th®t the work will be in conform mce with the Ordinances and codes of ttte Ciy of
Eagan; that I understand this is not a permit. but surly an appuoadon fa a permk, and Morrk k is not to titeA Ndthout a
a00ord®nq with the approves plan in trio ce" or %VDM wttlt:h regWre d rabieW and approval plans, permit: that d w Nark will be in
E"0"rior work authoriz8d by a building permit imuod in accordanco with the Mtinnesoia g~ gulldl
days or WWI: isetmnce, Code must be completed within 180
aAt,,~ ~~2.R►s
appllcanCe Printed Name x
Applicant's Signature
Page 1 of 3
TO/TO 39Vd 1NIVW 1X3 139 L9Z9T98ZT9 bS:OT bTOZ/LZ/SO
• Use BLUE or BLACK Ink
I For OfNce Ua�e�y.r-----—�
(���} f c� I Pemtit�f •�J� (
U11�� Ol �U � � i �� . 7� �
� � Pe Fee•
I
3830 Pllot Knob Road
E��n MN 66122 j Oate Reaeived: j
Phon�:(651)87fi�6676 I �
Fax:(6s1)s76�s68a � � �
�
�----___.�-------__..
20�3 RESIDENTIAL BUILDING PERM�T APP�ICATION
Da�e: S� ,!�/ ,d�sy SG,S"a�,l�, G�., G��/
SFte Address:is�b�,��;'��.�7:t, 7`/�y�. So�rr/iPa�•J 7-� � Unit�:
;J�,:::�.�. N�,e:��o A e r �►�.�a��n� Lv; .7-a e Phone:��3 -s-�� - ���o
� , Address/City/Zip: �l S� 1� ��.►4�'—�,2 A✓ �u � ,2 19 �oi,.�E.; (�i�'t�r'
, . �,�,� s.��x ti
� � Applicant is: Owner �C Contractor
� . .,..,. . D�scripdon of worlc: Q E K o✓� a 2 ti-P��c� �Ai�1 e'o
TYp�,,�f 1IV!'or�c
� Construct;on Cost��9 �� r Multi-Family Building:(Yes�/No�)
. .. . .. . ,. " Company; ��.! �,�'r'f_!��o R /1'1?�i.a� �+�--� Corrtact �v4 v� �J f��(�R�5
����or��.-;. Aadr�ess; �os k� 6�� S>. �;�,. �PGS.
, �': _' � State: �� zip: SS'�/� 9 Phone: �O'.; - �C�i- �x 4/3
� .� , Llicenr�e� �� ��/J I 3/ lsad Ca�tificab#:
If the project is exempt from lead certification, plesse explain whjr:(see Page 3 for add'Rional iMormation)
�L�loS L.��2� �v�Lr Pos: / Q7 �'
CpMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW 6UILDIN�
�n the last 12 mo��,has the Ctqr af Eagan Issued a permit for a simitar plan bs�sed on a rna�be�pla�n?
Yes ".,No If yds,dabB and addnass of master plan:
Licansed Plumber: Phone:
Mecha�ic81 Contractor. PhOnO•
Sew�r&Weter Contractor. Phone•
NOT�:.R�al�a�o�d� .. � . ,' K .. ,
� �. .��'� :-'� . •. +e, ,. ,. . �. � �rJ'
• bf@.;� . , • • ••' .
':Y� '� ;�'.K�"��� :,j',"%,.;.,,;� r� �. 1., ,,a.. , � � �Y"�s�
�. :�t-� �,i:. 4:A: ,� a •,�f�• +��o.�5r,?ui;:.r�..v�
C�.4 B�EQB�Y�U D�• Ca��Gopher Slam One Call et�661)45s.ppp2 fcr protedion aqainsl und�t+ground utlll[y Camege. Call 46�oura
Defo�e you�r�end to dlg ro reoeive locetes of underground udlrtJes. �W W.�O]Lh615t8t�OneGgll.om
I her�by aGcnowlQdge that this infama6on is oomplele and accurete;thet the work witl be in confamance with the wdinences and codes of the City of
Eagdn; tl1aC I under�nd this is npt a p0lmit,but oNy en OppGcetion for a p�►mit.dnd wak i6 noC to start withart a parnut: 1haR the waic will be in
aoconea�ee wkh tha approve0 p1511!n tne case W woffc wRICr1 I�DQWr�9 8 18vi@w 8f1Q BpplVVel O(p18n5.
Ex�ria'+wwk autho►i�sd by a bullding pBrm7t lssued tn accord��ce wfth tDe Mlnnesota st�e 8ulldln Cods must M complebd wkhln 180
days of psm�ft issupnCe.
x ��i�r� ��R2r5 x
AppllcanYs Printed Name APPllcanY�SlgnAture
Page 1 ot 3
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