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Use BLUE or BLACK Ink
r - - - - - - - - - - - - - - - - -
I For Office Use ~j
; Permit
City of EaRd 15
I Permit Fee:
3830 Pilot Knob Road I i3 I
Eagan MN 55122 I Date Received: I
Phone: (651) 675-5675 I f1
Fax: (651) 675-5694 I Staff: V, I
2013 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: I Site Address: q0- l 4 Unit
I Name: Al Phone:
Resident/ v,3~ C r FC v1 AM ►J 4_U 2 Z
Owner ~ Address / City / Zip: ~ t"
Applicant is: Owner `V Contractor
Description of work: P\", '
Type of Work i
j Construction Cost: 171 (.Q DO Multi-Family Building: (Yes //No
)
i Company: Contact: L~ 3` 3 ~3
II L tom -drag -10 L ~
Contractor Address: :D36 i) 77 t.~ City:
State: Zip: l~- Phone: % - e 7-x{777
' License Lead Certificate
certification, please explain why: (see Page 3 for additional informati/on)~
If the project is :7 mpt from lead
I ~t lam' Cl` ~ V\ V d~~ J L fiC~ ~Dw' , 'il 1 ,
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
j 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._qopherstateonecall.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 W a VV%_
X
Applicant's PriAted Name ure
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