1757 Bluebill Dr ,r
4 _ x`15 ~ , S~ i ~ -is~-, 115'1 '~31 u~"► Ca
Use BLUE or BLACK Ink
For Office Use
1 Permit { 1 U ~J { ~7 i
Win
C, of Ea ►
I Permit Fee: = '-I a ~
3830 Pilot Knob Road i 2 ►
► Date Received: 2~ I J '
Eagan MN 55122
Phone: (651) 675-5675 a,n(Z i
Fax: (651) 675-5694 i Staff. -LLB-
0-I0 t------------------
2013 RESIDENTIAL BUILDING PERMIT APPLICATION
1(?°o"I-f3 Site Address: 1751 1-753 i7S5 1757 ltd-Ilo C;cc.ld Unit#:
Date:
Phone:
t Name:
Resident/ i
9 Owner 1 Address / City / Zip:
I Applicant is: Owner Contractor
i Description of work:
Type of Work
g Construction Cost: i 50 0 Multi-Family Building: (Yes I No )
Company: Dc-\-, oeA!-e- Acr- F + ~Ic~rian Contacct- 4O Dckr ~
t,~ C3 L~ 1 ~r~ : Cax Z)r d City: i r nn4 rmlr.~
Contractor Address:
State: 01 A) Zip: Phone: 5 - 29ao
I ,t
License #:)~--9Lv 5 `t Lead Certificate A t~3 T-
-
If the project is exempt from lead certification, please explain why: (see Page 3 for additional information)
Y 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 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 Cali at (651) 454-0002 for protection against underground utility damage. Cali 48 hours
before you intend to dig to receive locates of underground utilities.
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 ~K Uc cActr X
Applicant's Printed Name Applicant's Signature
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