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12/1/81_ 22142 100100 pd
epee to a with the Cilli, ef e, Conned 425 i„ 0 p
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c Permit°'Nt: N. 101 n) pet
\ ,- Surcharge: ` G, C 0 pit
6th,.
„., Date Paid:
Date:
City of Eapll
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
r
Use BLUE or BLACK Ink
For Office Use
Permit #:
Permit Fee:
Date Received:
Staff:
2012 RESIDENTIAL BUILDING PERMIT APPLICATION
Site Address: 1/05- ' C 3-7 (Cir ut cfi
Unit #:
Name: rin/ / (/ GG Phone:
Address / City / Zip: / /0-5-, ✓A i ✓a ' Dr) v"e
Applicant is: Owner Contractor
TYPE OF WORK
CONTRACTOR
Description of work:
Construction Cost: ��GC CC
Company:
Multi -Family Building: (Yes '/ No )
/G% r—i 4.0Contact: 767—
Address:
Address: ��- /4//.,5
//
State: ////1/
License
/N//l_Th
Phone: ,
City: !r7" ./9/e
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:
Mechanical Contractor:
Sewer & Water Contractor:
Phone:
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) 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 Buildi
days of permit issuance.
X
Applicant's Printed me
x
Applicant'- %-ignatur
ode must be comp#4ted within 180
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