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4312 Clemson Cir CITY OF EAGAN WATER SERVICE PERMIT 3830 Pilot Knob Road P.O. Box 21199 PERMIT NO.: Eagan, MN 55121 - DATE: Zoning: No. of Units: Owner: Address: Site Addess: Plumber: Meter No.: Connection Charge: Size: Account Deposit: Reader No.: Permit Fee: I agree to comply with the City of Eagan Surcharge: Ordinance Misc. Charges: Total: By , Date Paid: Date of Insp.: _ 7 - , Insp.: CITY OF EAGAN SEWER SERVICE PERMIT 3830 Pilot Knob Road P.O. Box 21199 , PERMIT NO.: Eagan, MN 55121 DATE: Zoning: No. of Units: Owner: _ Address: Site Address: Plumber: 1 agree to comply with the City of Eagan Connection Charge: 25 Ordinances. Account Deposit: Permit Fee: Surcharge: By Misc. Charges: Date of Insp.: Total: Insp.: Date Paid: i Use BLUE or BLACK Ink For Office Use--------- , ~~t j Permit 1 I j Icy of Eap I Permit Fee: c, 5- o~ 3830 Pilot Knob Road I I Eagan' MN 55122 I Date Received: Phone: (651) 675-5675 I I I Fax: (651) 675-5694 1 Staff: all `___-_____U______J 2013 RESIDENTIAL BUILDING PERMIT APPLICATION Date: Site Address: ((fit f ( ~f 3 0-13 lo~~Ytt SO,U 6~_Unit Name: !P-a[ of Ao!✓4 A S ~l,-/ 14,L /9 M /'1 Phone: Resident/ Owner Address (City /Zip: Applicant is: Owner Contractor I Type of Work Description of work: K~Qee pf ~t,0IwJ - Construction Cost;_ v _ r.____.~_l~Qulti l amity ~aitdrflg~ {~`es / No-~-- ` L8 h vL Company: Contact: I Address: Ci3 ,Gfaf.a'16 _4.r0f,, City: Mo L i Contractor ~ Ylr1~n ~ ~ra~- State. Zip: Phone:" NAT.- Lead I Liserfse#:- - - _ e i ica e . If the, project is exempt from lead certification, please explain why: (see Page 3 for additional information) D &1'v,,I~ - 5 f 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.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 l 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 Code must be completed within 180 days ofpermit~,issuance. x-1162~ V`t 1e x Applicant's Printed Name Ap 'cant's Signature Page 1 of 3 ii u