1688 Covington Lane � � I C�g�--(, � ���' , l c��Z
� � tlse�LUE ar BLACK Int�
! ForC�EiceU�ae--------- f
� i Permit# ������ j
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3830 Pilot Knob Road ;
Eaga�MN 55122 j Date Receiv�d: �
Phone:(657)675-5675 I i
Fax:(651)675-5694 i Staff: I
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2014 RESIDENTIAL BUILDING PERMIT APPLICATIQN
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Date: �!'"�!� Site Add�ess: Unit#:
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Name: ��?�T"/�i�� ���... !t�e��Gt�i C..� Phone:
Residentf
ownec add�e�s i c�ty i z��:_��'���- �i�
aPPiicant is: (3Hmec � Gontractor
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Type c�f lAfo�ic;
Qescriptionofwbrk: ��'''�''' �?�� � �'G" '���`
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Cans#ntction Cost: � � Multi-Family'8uilding`(Yes � /Na_,�
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Company:[t/C?YZr��5� G vYi�t�r��'�fh�5 '� Contact c/�'f'�'a'/�G�iJ�f%
Cantra�tor Address:Q�1.��'l �✓�'ir��` !�� Lr,�-y�z �s c;�y:���'�'�- �!�t,���
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State:�Zip: .��`1 Phone:���''���'"D'rEmail:,lrm�$7�1t3v'L��`7'��v�`�d����r�
Liaense#: �� ��� � 7� �s�c�-C.�r�-�.
t.eaa certificate#:/V.�a.r°,-r»�t'�3 °I
if the project is exempt from Jead eertification, piease exptain why: (see Page 3 for additional infermation)
C�MPLETE THtS AREA ONtY fF CON�TRUCTiNG A NEW BUILDING
� . 4 � . .. �. . . . . . . . . . . . .. . . . . . . . . � . . .
�� In the Fast 12 mont , agt `he Cily of Eagan iss�d a permit€or a similar plan based arr a master ptan?
.Yes _No !f yes,date and add f master p(an:
Ucensed Piumi�r: Phone:
Mechanicai Contractor: .
Sewer�Water CaM _ Phone: �
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/�F!?TE: s and�u#ipo�r�g dacum►enf�tha#ya���6r��t�re consfdered`tc�be p�blic ir�re�m�#��. ���o�s�t' ;
mf�rrrt�ation�ray be�/"a�s►�`ie�if�s non prrhiic if�otr�►ravf�►e spec�c rea�oRS that wqufd�it#�i+s�r�jr'#o
� - � �������co»cluc�t� � ' � ��� s�iae�ir`ar,�e s�r�ets. � � ;, � � �;. - � -�
CAtL B�EORE YOU DIG. Cali Gophet&ta�One Ca11 at(651}454-0002 for prutectian against underground utiiiity damage_ Cai!-48 hours
be#o�e you intend ta dig to recefve locate.s of underground uiilities. www:aooherstateonecatl.ofa
I'hereby acknowledge that#his infarmation is c�np[ete and accurate;that the wrorlcc wilt be in�onformance with the ordinance.s ar�cx�des of ihe City af
Eagan;that 1 understand fhis is not a permit,but oniy an apptication for a peimit, and v+�rk is not to star#with<wt a permit; that the work wil#be in
accorclance with the approved plan in the case of wrortc whiet�requireg a reviewr and approvat of ptans.
Exterior work autharized by a buiidir�g permlt issued in acc�dance with the Minn�ota&take Id1ng Cade m�t be compieted with9n 180
days of'p�rmit issuance.
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ApplicanYs Printed Name ^ anYs Sigrtatute
' ; Page i af 3