1534B Clemson Dr CITY OF EAGAN Permit No: Date:
3830 Pilot Knob Road Meter No: Size:
Q.O. Box 21199 Reader No: Date:
Eagan, MN 55121
Owner:
Site Address:
Plumber.
Conn. Chg: Zoning:
Acct. Dep No. of Units:
Permit Fee:
Surcharge: I agree to comply with the City of Eagan
Tr. Plant Ordinances.
Meter:
Misc.: B 4.1 ,,,, - 7
WATER SERVICE PERMIT (6e)
CITY OF EAGAN Permit No: Date:
3830 Pilot Knob Road B/P No: Date:
P.O. Box 21199
Eagan, MN 55121
Owner:
Site Address:
Plumber:
MWCC: Zoning.
City Chg: No. of Units:
Acct. Dep:
Permit Fee: I agree to comply with the City of Eagan
Surcharge: Ordinances.
Misc.: By
SEWER SERVICE PERMIT
•
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Use BLUE or BLACK Ink
For Office Use
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City of Permit Wan I ~G I
Permit Fee: ,
3830 Pilot Knob Road
Eagan MN 55122 j Date Received:
Phone: (651) 675-5675 I I
Fax: (651) 675-5694 1 Staff: I
I I
- - - - - - - - - - - - - -
2013 RESIDENTIAL BUILDING PERMIT APPLICATION
VVI Date: Lr~ r Site Address: C ~ y ~1 ~ Y i V Unit
i c, i< s
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Name: I C I l/ 1~ ~ 4 f 1 ~ t/~, Phone: I`'
Resident/ - ~a - ~ r~ _
Owner Address/ City/Zip: 4-n Q i y ~ 00 1~1 I i
Applicant is: Owner Contractor f
Type of Work Description of work: 0 yy C4 MW, I_ ( C* I C
Construction Cost:`. vo ~ Multi-Family Building: (Yes X / No )
Company: T1ccc ) r1 v LL- J Q E6? tGtfl'( i' `i< tact: e 1
Contractor Address: CDOD Lx.['.a~s/Ov-- 6J od city: , S4, Lo1_i5 P~ k-
State: h Zip: Phone: aQL- 9 14 - -72"
License ~--1~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 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.goaherstateonecall.oro
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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Applicant's Printed Name App ' is ig ature
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