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Zoning: _ "
O ner:
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meter No. Connec n ch
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Permit Fee:
Recsittr Iii n Sun�wrge:
t epee N Abe of Sego
Misc. Charges:
Total:
Dote Paid:
By a of Insp.: � - r , � insp
• ; SEW, SHt 'PER
cry ProlliA4SAN PERMIT NO.:
1195 Mot KiaY Rood PERMIT
Z on i s IrtN S5122 Zoning: No. of Units:
Owner:
Address:
Site Address:
Plumber:
1 woo to coo* rr;tb ibe City of logos Connection Charge:
Account Deposit:
Permit Fee:
Surcharge:
Misc. Charges:
By
Total:
Date Paid:
Use BLUE or BLACK Ink
r
For Office UseI r(~ ;
Permit
City of Eap
Permit Fee.
3830 Pilot Knob Road I I
Eagan MN 55122 Date Received:
Phone: (651) 675-5675 I I
Fax: (651) 675-5694 I Staff: I
I I
72013 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: 3
147,L .4~
Site Address: 7'~+1 y~ZS ~/x X711 Unit
Name: lJ ~ Phone:
Resident/
Owner Address / City / Zip:
Applicant is: Owner Contractor
Description of work:d L'
Type of Work
Construction Cost: f 2,0d o J J Multi-Family Building: (Yes / No )
Company: Contact:
Contractor Address: ~~~Dr~ Gfi City:
State: Zip: Y2 7 Phone: 7
License Lead Certificate
If the project is exempt from lead certification, please explain why: (see Page 3 for additional information)
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?
_Yes _No If yes, date and address of master plan:
Licensed Plumber: Phone:
Mechanical Contractor: Phone:
Sewer & Water Contractor: 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) 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.
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.
x x'
Appl ant's Printed Name Applicant's SignaHFe
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