3764 Burgundy Dr
Use BLUE or BLACK Ink
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City O1 ~anV R I Permit L,~ I Permit Fee: / 3 I
3830 Pilot Knob Road I I
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Eagan MN 55122 Date Received:
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Phone: (651) 675-5675 I I
Fax: (651) 675-5694 I Staff:
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2013 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: Site Address: 7 c2,74 Unit
Name: .gel) eza ztmoe/' Phone:
Resident/
Owner Address / City / Zip: Z 7E.2 - 17ey f' /r4 ah~~ir
Applicant is: Owner Contractor
I Description of work:
Type of Work
Construction Cost: Multi-Family Building: (Yes / No
m~ Company:Contact:46/
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Contractor Address:'2/~ S'v~i~rz~-~ ā _Sā ;280 city: /Tdl~
State: Zip:Phone:
License #:w Z? 6 1;~ 1;? 410 Lead Certificate #:4147-0_7912
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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?
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s _Yes _No If yes, date and address of master plan:
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Licensed Plumber: Phone:
Mechanical Contractor: Phone:
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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.orq
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 Applicant ' nature -
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