1331 Crestridge LaneC!ty of Eaau
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675 -5675
Fax: (651) 675 -5694
Date: Site Address: Unit #:
RESIDENT /
OWNER
TYPE OF WORK
CONTRACTOR
Applicant's Printed Name
2012 RESIDENTIAL BUILDING PERMIT APPLICATION
Name: /11,
Address / City / Zip: t 32 7
Applicant is: Owner
Description of work:
Construction Cost: 61'
Company: 461/1„..,-4r
Address: g Z 712 :0 -, GJ / G
State: A- Ifs— Zip: ; 3 (I
License #: g G I f 't 73
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XContractor /y/ /G ?r'�� / 321 / 3 3 / / 33 3 /3 3 )' r
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Phone: 6/2 _. l - g j C7
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 i
the information may be classified a nori'- pudic if y ou p toy/de specific reasons
c onclude 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.
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Use BLUE or BLACK Ink
For Office Use
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Permit #: 37(1.-75
Permit Fee:
Date Received:
Staff:
Phone: G 5 3 -1 -18 2 9
Multi - Family Building: (Yes k / No )
Contact: r ( Y�
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;" pp cant's Signatur
Gam? 6"9`%` 557 a'
Mt .vim'
., formation. Portions of
ould permit the City to
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