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1955 Gold Tr CITY OF EAGAN WATER SERVICE PERMIT 3795 Pilot Knob Road PERMIT NO.: Eagan, MN 55122 DATE: Zoning: __ _ No. of Units: Owner: Address: Site Address: Plumber: Meter No.: —_— Connection Charge: _. Size: __ _ Account Deposit: Reader No.: Permit Fee: agree to comply with the City of Eagan Surcharge: Ordinances. Misc. Charges: Total: /C r 711.-) Date Paid: Date of Insp.: Insp.: CITY OF EAGAN SEWER SERVICE PERMIT 3795 Knob Rood PERMIT NO.: E4an, MN 55122 DATE: Zoning: No. of Units: Owner: - -- Address: Site Address: Plumber: I agree to comply with the City of Eagan Connection Charge: _ Ordinances. Account Deposit: Permit Fee: Surcharge: By Misc. Charges: Date of Insp.• Total: tnsp.• Date Paid: Use BLUE or BLACK Ink r For Office Use l I ; Permit City of Eap I Permit Fee: 3830 Pilot Knob Road 1 7 1 Eagan MN 55122 ; Date Received: 3 I Phone: (651) 675-5675 Ir I Fax: (651) 675-5694 I Staff: ) I I I 2013 RESIDENTIAL BUILDING PERMIT APPLICATION Date: 0 /12 2 3 Site Address: 1 s 3 l ~s~ ~a icy 1 v &oe. c* Unit Name: ~~iq - s41o r+~tO &l Phone: 6.5'1- .39? -S''7 I Resident/ I I Owner Address / City / Zip: /.-q' 7 2 EG--7/,Q /,3/c, 64- !~/c Applicant is: _X Owner Contractor Description of work:42 do ' ~n ~w s S/ dr- of Work ' Pe Construction Cost: o Multi-Family Building: (Yes / No ) ' Company: Contact: i Contractor Address: City: State: Zip: Phone: j License 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 _KNo 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 the 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 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 t issuance. x - dL x o Ap ant's Printed Name App icant's Signature Page 1 of 3 Z' ~ J-7