4722 Tana Pt -.. ° �. .. ..WATER SERVICE PERMIT
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in's Knob Row
&span, -MN . 153122 DATE:
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Owner:, r„� . a# alnitss
Address:
Site Address: 4 , f
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p' + ` i p Connection charge: ,, t
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:
8y
Date .
t i n _ Misc. Charges:
iru Total:
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Use BLUE or BLACK Ink
r
I For Office Use
PermitM
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City of EaRd I 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
2013 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: Site Address: 4 722 - Y7 j y Unit
Name: I6~ -rile ~/s r Phone:
Resident/
Owner Address / City / Zip:
Applicant is: Owner Y Contractor
Type of Work Description of work: d
Construction Cost: Multi-Family Building: (Yes / No )
~~lh~'~ ~1'eYf
Company: oA12-ejx t Oilve 9,';,,
Contractor Address: 3,-2-&5- S 1 PFi°Nz-,O 64- City: ~JLs.~ir 1 l
State: All, Zip: Phone:
License 903*® 6` 6 / 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. I
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.org
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 D6~ r . {~~'t' scy7 x
Applicant's Printed Name Appli s Signa ure
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