1253 Timbershore Lane Jul 28 2014 09:51 AM HP FaxGates G.C. 7634987710 page 20
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� ForOffieeUse---------�
� j Pertnit it:_ ' �`/ � /G� I
Clt ! 0�����Il � Pertnit Fee: /�� V� �
3830 Pilot ob Road � -�r� �
Eagan MN 122 � Date Received: b _ �
Phone:(65 675-5675 I I
Fax:(651�6 55694 I Staff� � I
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014 RESIDENTIAL BUILDING PERMIT APPLICATION�
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Date: �' ,'=, Site Address; ��'� 'Z'� Q '`�J`; ,' �i-� ; �"`�e`'�A.o� Unit�:
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, Name: , r�ri c.�%l.o✓• , <-.' Q� Phone: (o� � . � -
Residentl ,
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Owner Address i Ciry/zip: J C,c- �
Appiicant is: Owner ''�Contractor
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Description of work: !C�*-' ��� �"r�.?
Type of Work ��
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-Construction Cost: i/_�r �' � �/ �- Multi-Family Building� (Yes " /No_J
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'Company:�='o-!�� ��i'�- .�'r'�i�.c�`of' Contact: �'�✓v( ;e...
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� Contracto� Address: <>� �- �:,�;.Sb�-� ,�/'� City. �'' ;i'��'�`��`.
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` State: %�/Y Zip� S� =(� Phone:-v�L;�3�'.��-1 r /,�C.�=y � �/�' r�.<::tirf.
� Email: � G-r,�ftej.'�vu.,i,a�%: �.
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� License#: L'= ��v�q--j Lead Certificabe#: /�_��; �"�=. �'�` -
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If the project is exe, pt from lead certification, please explain why: (see Page 3 foradditional information)
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COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
� In the last 12 mont ,has the City of Eagan issued a pertnit for a similar plan basod on a master plan9
_Yes _No I yes,date and address ot master plan:
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� Licensed Plumber: Phone:
Mechanical Contra r: Phone:
' Sewer 8 Water Con actor: Phone:
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NOTE;Plans an supportinq documents that you submit are considered to be pubJic information. Portions of
� the irrformatior� ay be classified as non public if you provide spec�c reasons thaf would permit the City to
fi" conclude that the r�are trade secrets.
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CALL BEFORE Y � DI . Call Gopher State One Call at�651)454-0002 for protection against undergraund utilily damage. Call 48 hours
before you intend to dig receive locates of underground utilities. www.goeherstaleonecall.om
I hereby adcnowledge t t this information is oomplete and aecurate; that the woric wiil be in confortnance wilh the ordinances and codes of the Ciry of
Eagan;thal f unders this is not a permil, but only an application for a pertnit, and work is not to slart without a permit; that the work will be in
accordance wilh the app ved plan in the case af work which requires a review and approval of plans.
Exterior k authoriz hy a bullding it issued in acco�ance with the Minn Bullding Code mus e eompleted wifhin 180
da rtnit isouanc . �
x � x
Appli nt's Printed ame App canYs Signature
Page 1 of 3
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