1881 Deer Hills Tr
Use BLUE or BLACK Ink
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rmit#: 5 5 d c;l
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Vitt' of I Permit Fee: > t
3830 Pilot Knob Road I I
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Eagan MN 55122 j Date Received: -1
Phone: (651) 675-5675 I I
Fax: (651) 675-5694 1 Staff.
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2013 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: 10t l Site Address: 1I t. J'P e r" 0(5 {-'G1 l Unit
Name: l~ ~l N Phone:
Resident/
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Owner Address / City / Zip: l_ b ( k! -P 2
Applicant is: Owner Contractor C
Type of Work Description of work: r C
Construction Cost: Multi-Family Building: (Yes / No
Company: q l `I t 4el_IA~ I Cbntact:C --s' PL
Contractor Address: 9 ~i l0. ~uC City: _1 I C A Ud-L( -Q
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State: Zip: d" Phone: ~q o 1-4
License JL_ 12' aCt -1 Lead Certificate /A I _ V 4,8
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 _No 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 we considwwd to be public irtfi wilvatfor+. Portions of
the information may be classitied as non-public if you provide rspeclik reasons' that woidd permft the City to
conclude OW th are trade secret
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.ora
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 Mi Slate Building Code must be completed within 180
days of permit issua
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Applicant's Printed Name Appli rW Sig tune
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