3882 Dolomite Dr
Use BLUE or BLACK Ink
For 01110108 t`iesp~ -
j Pemnit s': I
MY o f Een
of t Permit Fee: OD I
3830 Pact Knob Road
Eagan MN 55122 I owe Received: I
Phone: (651) 675.5675 1 I
Ste I
For. (651) 6758694
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2013 RESIDENTIAL BUILDING PERMIT APPLICATION
Does: - Z - / Site Address: 3 7 a~73, 3 580, 3B S R ADC-o M -T y IS12.. Unit t::
Name: Phones 7-6 3 S 3 4 7 7 0
IieSlderitl
Owner Address / City / Zip: RSO D Z e 14'7-v Q Av, A), JA Goad V 10r 40.4
Ss' S/4 7
Applicant is: Owner Contractor
Type'•o.fWork Desc"on of work: PIZ-* ~ f a- R £ PC. *e- S !J /,J ~ d ~idsG ~ •s /r1 Z 7-4 L
Construction Cost /00• C>•t7 _ Multi-Family Suilcift: (Yes / No _J
Company: 9AI o /L Mitt •7 ,0•r . Cam Contod (JA V , 0 49,,IZA S
Address: /mss" Goon f77. City: /V PG. S
Coat>raator
State: Zip: SS'"// 9 Phone: [o/ A - -Y !o .21/3
ticense ff: fS C- V// / 3 / Lead CerWicate
If the projed is exempt from lead CerNflcration, please explain why: (see Page 3 for additional information)
%Lb,&S• Q~rLti- Poste /F-7y
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW 13UILDING
In the wet 12 months, has Vw City of Fagan issued a permit for a similar plan based on a master plan?
_Yes Flo If yes, date and address of master plan:
Ueensed Plumber. Phone.,
Mechanical Contractor: Phone:
Sewer & Water Contractor. Phone:
NOT PAM MW
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SIP
66 4~M'alml0f/oil:!Sr 9Mo►+viu►srM
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CALL BERORE YOU Di Can Gopher 3440 One Call at (661) 45444 for prolsWon against undogmund My damage. Call 48 hours
before you Intend to dig to rooave locates of underground utgWw. WM22oherstaton®can.0ra
1 hereby aft AWP that this kbTwtton is complete and aaxuate: trot the work will be in eonfomtance with the ordkrar m and codas of the City of
Eawn; t ce I undwct&W M Is not a permit. but o* an appncaSon for a permit, and work is not to start wiUaut a permit, that be nark vAN be in with tw approved plan In the case of
wont which requires a ravlewand approval of plena.
Exterior work i Iii iWe I by a building permit issued in aaco►datnoe with the MinneSote Staff BuUdft Cods mwot be completed within 180
~ ~ Per++►it isiluarres.
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Applicant's Printed Name Applicant's Signature
-7 7 ~ Page 1 of 3
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