1615B Clemson Dr CITY OF EAGAN WATER SERVICE PERMIT
3830 Pilot Knob Road
P.O. Box 21198 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:
Ordinances. Misc. Charges:
Total:
By Date Paid:
Date of Insp.: a, 7 — Insp.:
•
CITY OF EAGAN
3830 Pilot Knob Road SEWER SERVICE PERMIT
P.O.Bo ..21199
Eagan, MN 55121 PERMIT NO.:
DATE:
Zoning:
Owner:
No. of Units:
Address:
Site Address:
Plumber:
• I agree to comply with the City of Eagan Connection Charge:
Ordinances. Account Deposit:
Permit Fee
By Surcharge:
Misc. Charges: _
Date of Insp.:
Total:
Insp.: Date Paid:
•
•
•
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Use BLUE or BLACK Ink
For Office Use
4 I
j Permit City of Eap Permit Fee:
3830 Pilot Knob Road I 13 I
Eagan MN 55122 i Date Received:
Phone: (651) 675.5675
Fax: (651)675-5694 1 Staff:
I
,1 / /2013 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: OI 6 / 3 Site Address: !Unit
021
Name: -LAl2J✓ al L& ff,b - Phone: ~Z 7 7
Resident/ J
Owner Address / City I Zip:, / r/i/~ f' ~b~ 42z
Applicant is: Owner Contractor
Description of work: dt- ?k /2 i S~
P
gype of Work,
T
Construction Cost;.
Company: No)-
-rL8 ~aUVWxl ~ h Contact: oe rlL e, S
I gr,3q~ k4a5".C1mte, f`F city:'11 L(we(La
Contractor Address:
Stater Phone'
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t-eerrser _ . egad SRI cfi afe
If the project is exempt from lead certification, please explain why: (see Page 3 for additional information)
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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:
11OT Rlans. nd su "ing do'cuRients thatyousubmit=are,consde ed;to be publrcl.,forrriafonrt, of
the information.may be classified as non public if.you proyide specific reasons that~would f,e Cit o
concl~rdo- fhat~they are trade secre s
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, jo=,gogherslateonecall.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 Minnesot tate ' u Idln Code must be completed within 180
days` of permit issuance.
X_ fp V IzQ I~V e x ~P
Applicant's Printed Name Ap 's Signature
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