4601 Penkwe Way '�cQ(7�� L-�(�(,� `��-, �l C�v 3 , y�a U� ��a— UsejBLUE ar BLACK irtk
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t��6 O��� t� RECEIVED , P�,��:
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3830 Pilot Kr�ob Road ��� ��� Z�
Eagan MN 55'1�2 j Date Received: i
Phone:(651j 6Z5-S675 1 �
Fax;(�1�6T5-5694 1 Staff: 1
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2014 RESIDENTIAL' BUILDiNG PEI3MIT A�PLICATI4N
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Name:L/G?fr!?Y�'� ���- ��tv�7 h�t— �Ph�one:
Residen�T
+�wn�r aad�es��c�r t z�p: ,�'�"'�� �''1�
Applicant is: Owner � Contractor
C)esc,riptionofwork: ��� c��� � ��' ��o��
�yp�of Wark e
Construc#ion Cos�: ��',!�!J � Mu�i-Famiiy Building:(�es .� /No_�
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Company:lif�YLc���;�.d1%s/r�-G.�t�/S `�. Contact t�j�''�'t /�E�iJ�'�
' Address:���j� Z.r�-1��� �s��- L�!�'3�'� /� City:��'�` ��G�J/'�.;�
COl1#f'�C�4C �
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State:E�Ta p: ��.�3�j r Phone:�j�J�7"��Ernail:t��r+r�fl Jr!�3�5fi G c3Yl'�+���7�v v .�-
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Lead cert�cate#:sV�a.-�°�- ..- r�1i. —l
If the project is exempt from iead certi�cation,please expfain why: (see Page 3 for adclitional inforrnation)
COMPLETE THIS AREA ONLY IF CONSTRUC7fNG A NEW BUi�DtNG
tn the last 92 maM , the City of Eagan�issued a permit for a similar plan based on a master ptan?:
Yes i,No If yes,date and addr ' f master plan:
L1cen�ed Plumber: Phot�e: `
AAechanical Contractor: ,
Sewer&Water Gorrt r. Phone:_ „�_
�tE�t7'�:- s ancT sujnpc�rdr��tlocumer�fs�iarf yocr�ubm�t are�nsia[�red ta ke p�bl,c��r�tat�or� -I°�r�r���f>
� r�fr�ni�ratiot�m�}r b��f�ss���s non p�,�ili�if you pr�vPtle sp�clfic rseaso,ns i�rat���r/r�pe�arr�;�ie G�,i;#o ''
cc��r�l�rd�fhaft are�de se�ea�ts.;
CALL S�FORE YOU DIG. ca���a�ner scat�o�e ca�r at�ss��asa-000a�or pr�tea►on agai��der9���y aama�e. can 4s na,r�
before you-intend to dig#o receive locates af underground utilities. www.qoohersfateonecatt.arp
I hereby ackno�nAedge that this irifoRna#ion is comp�#e and aasurate;#hat the v+rorlc will t�in confo�rnanca witt►�e ordinar�and codes af the City of
Eagan;#hat 1 undetstar+d this is not a permit, bui only an applicafiort for a pemtit. atid wwk is[rot to atalt wiihout a pe►�r►it;tltaf ihe work wit4 be in
accardance with the approved ptan in the t�se of wvrtc which requi�a�view and approvat of plans.
Exterior work author�i by a buiiding permit iss�d in accordance with the M€nnesota Stats iding Cnde must be com�bed within 180
days of petcrtit issuanee.
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Apptican�s Printed Name • nt's Signature
' Page 1 of 3