3781 Grey Dove Lane
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Use BLUE or BLACK Ink
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I For Office Use 1
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Permit#: VO 3b2
City of Ea I Permit Fee: I
1
3830 Pilot Knob Road I t
Eagan MN 55122 i Date Received: 'D 2p I
Phone: (651) 675-5675 I
Fax: (651) 675-5694 ! Staff
# 9 L - - - - - - - - - -
2013 RESIDENTIAL BUILDING PERMIT APPLICATION
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Date: w '1- l3 Site Address: 37i~7 3 71 , 3>73y 3777 7 21 Unit
Name: Phone:
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s Resident/
( Owner Address f City / Zip'
Applicant is: Owner Contractor
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Description of work
Type of Work
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Construction Cost! J oLU+O p Multi-Family Building: (Yes f No
.,.....~..w... _ Company: Conte
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{Address: e-cL, r , City:
Contractor
State: (y),AJ Zip: _-)'5343 Phone: 1 52 3-/ ~2 - 220-0
License # 4~ ; ~y `1 Lead Certificate ~OooC
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 pen-nit 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 maybe 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.
I hereby acknowledge that this information is complete and accurate that the worse 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.
Applicant's Printed Name Applicant's Signature
Page 1r of 3