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3786 Burgundy Dr ,i1~c~l'en~ Use BLUE or BLACK Ink I---------------- I For Office Use I f City l"' Permit ~ I bb I Permit Fee: ' I 3830 Pilot Knob Road I I Eagan MN 55122 Date Received: Phone: (651) 675-5675 I I Fax: (651) 675-5694 I Staff: I 2013 RESIDENTIAL BUILDING PERMIT APPLICATION Date: Site Address: 378-11- e7 4- I -e4 /✓r° ilOnit i Name: ~enE Phone: Resident/ d' r' Owner Address / City / Zip: I Applicant is: Owner _)C Contractor i Type of Work Description of work :T ,C e ~ / Construction Cost: c Multi-Family Building: (Yes / No Company: ~el31he:s yehe~ e Contact: Contractor Address: - ~T9Q City: 1244 r State: Zip: Jf`7I3 Phone: alt ~ ?<31 ~ddr, -7 rt License #:Lead Certificate ~1,1161 f 1 vc. 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? i _Yes _No If yes, date and address of master plan: i 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.oopherstateonecall.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_ < 3( L L.~- I V l V" X Applicant's Printed Name Applicant' Signature Page 'of 3