1275 Timbershore Lane Jul 28 2014 09:50AM HP FaxGates G.C. 7634987710 page 17
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� For Offlee Use �
� j Pertnit#: �� ""��� I
Cit of Ea�a� � Permil Fee: � • � �
3830 Pilot nob Road I I
Eagan MN 5122 � aate Receiued: �� /� �
Phone:(65 ►675-56T5 I I
Fax:(651) 5-5694 I Staff: I
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, 014 RESIDENTIAL BUILDING PERMIT APPLICATION
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Date: � �°� ' SiteAddress: L ` � i ' • - � Unitl�:
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Name� � �"`' � Phone: ��. �''
Resident!
� OWn@� Address/City/2ip� ,;� c• �r>o/c-•
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� i Applicant is: Owner " Contractor
.,...�.._..... Oescrip[ion of work:«-°-3-_ � --f,:��f�- ,.,..._.___��_.�....._. _�..
Type of Work � `
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; Construction Cost: . ' Multi-Famity Building:(Yes=/No�
�..,.,_ Company._.�r.�%'vS :�Cti+..P,�/,.�! ...:.c,.�i� p�,;. _._._.._ Contact: �/� ;".c. .._.,..�_____�_..
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� Address' ���� :/,•":=;.r?�="` �--/``� /-, City: �✓;-r.:�.%--•
� Co�tractor ��
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� State: / � Zip:-'� Phone > _ ���v, Email: ,�y!�..�r :����?;_,rc�'Y�ar�r>�..�,z-� ,
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t ! License#: � '' • '-' Lead Certificate#: �:r`,!?��'" `
If the project is ex mpt from lead certification, please explain why: (see Page 3 for additional information)
� ��W COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING Y�~^
In the last 12 mon ,has the Ciry of Ea�an issued a permit for a simila�plan basod on a mastar plao?
_Yes _No I yes, date and address of master plan:
Licensed Plumber. Phone:
Mechanical Contra r: Phone•
;
Sewer&Water Con ractor. Phone:
_....� . ___ —_ .�_ .:_,.....__ _.___ .:..... �...._ ...�...�.�_....._..._., ......._. _�
NOTE:P/ans an' supporting documents that you svbmf�are considered to be public inl�rmation. Portions of
1 the informatioti y be classNied as non public if yoa provide specific reasons that would permit the Cify to
�� conclude that fhe�are t_rade secrets. _ ����
...._.__.._..w ___�..,..�..�._....�..___.. ._.
CALL BEFORE Y I U DIG. Call Gopher Sfate One Call al(65f)454-0002 for protection against underground uGlity damage. Call 48 hours
betore you iMend to dig p receive locates of undergrvund uUlities. www.00nherstateonecall.ora
I hereby acknowledge t Mis information is complete and accurale; tliat the work will be in conformance with the ordinanCes and codes of the City of
Eagan; that I undersfary this is not a permit, but only an application For a permit, and work is not to start wilhout a pertnit; thal the work will be in
accordance with the app ved plan in the case of work which requires a review and approval of plans.
Exte�ior wor riz by a building pe issu In accordance wilh the Minneeata Stada Building Code must be completed within 180
days o it' auane .
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Applican rinted ame ApplicanYs Signature
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