1884 Deer Hills Tr Use BLUE or BLACK Ink
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I For Office Use �
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C� � Permit#: 1 ����t/ U �
1Uy Ol ����11 I Permi F : •�� �
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3830 Pilot Knob Road � )����,,�� �
Eagan MN 55122 � Date Received:-1TLL"�- I
Phone: (651)675-5675 I I
Fax: (651)675-5694 I Staff: I
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2014 RESIDENTIAL BUILDING PERMIT APPLICATIQN
Date: a f Site Address: ��8�-�l`� ��� �(� 7� Unit#:
Name: ��� �u6 Phone: ��a`3��" �3
R+�5�der�#1 - �HS� ���S'� � ��
. Qyy��r � Address/City/Zip: G J' � /�� �D�g
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�° „ Applicant is: Owner �Contractor
T 6 Of WOI'k ', Description of work: �c ��
�p Construction Cost:�
Multi-Family Building: (Yes�/No�
' Company: �rPsv,°-e-� /�a.�-c S��`/'�--5 Contact:
, Address: �3�/" S/� City: �e�c �r�ir c�
�Gil'�t'1C�QI" . .:
State: Zip:�"D�Q Phone:6�'9'�/,�8'S� EmaiL ���9,��.Yr�o��,,�,/. P0�
' License#: �����3 a Lead Certificate#: �v/�
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 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:Pl�ns antl sup�ortiny a►�cuments that you submi�are eons�dered#r�be public information. Fort+ons ot'
the information:may be classi�etl as�aon-pui�li�';if you�rc��ide specifie reasons that wa�ld permit the Ci�y#a
�anclude fha#the are trade�e�refs. '
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. www.aopherstateonecall.orq
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 Sta Building Code must be completed within 180
days of permit issuance.
x G-�iC'G� d [o�Jd� x
Applicant's Printed Name Ap licant's Signature
Page 1 of 3