2192 Water Lilly Lane , �. ,.;,� .� - Use BLUE or BLACK Ink
` i �orOfficeUse�r�_�_—��—I
•` � /01.� 79.s �
�lU� Ol ����11 �V"���� � Permit#: C��• CJ U
I �
i
I Permit Fee: �
3830 Pilot Knob Road AUC a 4 2014 i �f'� � � c�
Eagan MN 55122 � Date Received:
Phone: (651) 675-5675 � �
F�x: (651)675-5694 �Y:— i Staff_�`___,_`___^_ �
L�
2014 RESIDENTIAL PLUMBING PERMIT APPLlCATION
Date: �� ���I � SiteAddress:_a��o� �„j��C� ����L�, �
�
Tenant: Suite#:
R�SIdetIUOWt7@1' Name:�(����1. ���� Phone:��—c�L1�1'�.R��`�^-
Address i City/Zip: ' ) � �� � �
Name:��,��� ��1��G�1�.f``t CL�I License#: `Q�-�U�{'(p�}�O
COnti'BCtOt' Address` `TI��]I �3�� � ^ City: ��i�1�,V('
State: 'M Zip� ��- f ����
�� �Q��� Phone: � ��' �
' contact:2�,C�i� �mai�: �(' 1 rne� °cc� . ��
Type bf Wark —New �Replacement _Repair ,_fZebuild _Modify Space _Work in R.O.W.
Description of work:�,��C�(' �1��drC_5�
RESlDENTIAL.
�Water Heater
Waker Saftener
Lawn Irrigation(�RPZ!^PVB)
Pe1'r11i'�Tyr3e Add Plumbing Fixtures(_Main/^,Lower Level)
Septic System
New Water Turnaround
Abandonment
RESIDENTIAL FEES:
$60.00 Water Heater,Water 5oftener, or Water Heater and Softener(includes$5.00 State Surcharge)
$60.00 Lawn Irrigation(includes$5.00 minimum S#ate Surcharge)
$60.00 Add Ptumbing Fixtures, Septic Svstem Abandonment,Water Turnaround*(includes$5.00 State Surcharge)
'"'Water Tumaround(add$200.00 if a 5/8"meker is required)
$115.00 Septic SVStem New($10.00 per as built)(includes County fee and$5.00 State Surcharge)
TOTAL FEES$,_,,,��
CAi..L BEFORE YOU DI(3. CaU Gopher State One Call at(651)454-0Op2 for protection against underground utility damage.
Call 48 hou►s before you intend to dig to receive locates of undergrpund utilities. wvwv.popherstateonecall.orp
1 hereby acknowledge that this information is cc�nplete and aaxirate;ihat the work will be in confortnance with the ordinances and codes of the City of
Eagan; that 1 understand this is rtot a permit, but o�ly an applicatiqn for a permit, and is not to sta�t without a permit;that the work will be in
accordance with the approved plan in the case of work which requires a review and appr'oval ns
x X
Appli ant's Printed Name Applica Ys Signa#ure
FOR OFFfGE IJSE Reviewed By: Date: `,;,,,,,,�_ ,';
Required lnspecticns: ' Under Ground Rough-In Air Tes# �Gas Test Fin�fi
Meter Related Items: ' Meter Size Radio Read Staff: