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Amy (7) Use BLUE or BLACK Ink r - - - - - - - - - - - - - - - - - I For Office Use l/ I Permit City of Eap I P rmi Fee: I e t o2J 3830 Pilot Knob Road I Eagan MN 55122 SEP 4 2014 1 Date Received: A ~T Phone: (651) 675-5675 I I Fax: (651) 675-5694 I Staff: I 2014 RESIDENTIAL BUILDING PERMIT APPLICATION Date: Site Address: Unit Name. Phone: cos- qg00 Resident/ Owner Address/ City /Zip:_ Applicant is: Owner -V--Lontractor Type of Work Description of work: Construction Cost: Multi-Family Building: (Yes ~No Company: Contact: i Address: City: kfa2cl r S k Contractor State Zip: SS033 Phone: 6C(-2J0-KU Email: (/K6IG00 p e4zero, C.Uvt^- ~ License Lead Certificate 1If 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: Plans and supporting documents that you submit are considered to be public information. Portions of the information may be classified as non-public if you provide specific reasons that would permit the City to conclude that they are trade secrets. 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.gopherstateonecall.org 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. Exte 'or work authorized by a building permit issued in accordance with the Minnesota State Building Code must be completed within 180 days o permit issuance. x JAA u x S (/-~i( Applicant's Printed Name Applicant's Signature Page 1 of 3 MEMM