3783 Burgundy Dr
Use BLUE or BLACK Ink
For Office Use 2 I
f Permit ~J
City of E
I Permit Fee: I
3830 Pilot Knob Road I I
Eagan MN 55122 Date Received:`
Phone: (651) 675-5675 I fj~ I
Fax: (651) 675-5694 1 Staff:
I I
2013 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: Site Address: a/- Z7 F3 / C19 Unit
Name: Sewer ' ~ Phone:
Resident/
Owner Address / City / Zip:3'Z9®- 3_ZrRE3- 194-1^ dY D/
Applicant is: Owner _X Contractor
~ r
Type of Work Description of work: P..cZ!G(-nc S/ /
Construction Cost: / Multi-Family Building: (Yes / No )
Company: ~~✓J C1//4u-c,,4e.
Contractor Address: ,fG scrrn ,~h i .,712 City: _S_- ,go State: AV/ _ Zip: 6-6-L--1O Phone:
License 49 ey(o Lead Certificate
If the project is exempt from lead certification, please explain why: (see Page 3 for additional information)
s
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 supportingdocuments 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.gor)herstateonecall.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 Stat Building Code must be completed within 180
days of permit issuance.
x x
Applicant's Printed Name Applica 's Signature
Pagel of 3
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