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1177 Timbershore Lane Use BLUE or BLACK Ink ^For Office Use � I . � la���7� Clt of �� a� I Permit#: � � � � ��_� � � Permit Fee: � i 3830 Pilot Knob Road I � Eagan MN 55122 i Date Received: � I Phone: (651)675-5675 I Staff: � Fax: (651)675-5694 �________________� 2014 SEWER AND WATER REPAIR / DISCONNECT PERMIT Date: � !� ' ,j� Fee: $65.00 City Sewer City Water �Repair Disconnect Description Of Work: ,���/��iliC/.� �_,��/f¢�iP ,C'�'vtc�Z, Street Address for Proposed Work �/T ' r ����'�1�/%D/�E— G/� Name: 7'/w►t/1��[riYORr r�o.+��- /,'!.f'.l�C. Phone: �/.�• .Z 31• ���� Owner lnformation Address�City�Zip: �/'7 ,,�/�,/�,�i���'p�a �� L%r9�r��-- �... f' 1'A2� Applicant is: Owner x Contractor Licensed Pipelayer Master Plumber Property Owner Name:�70 �DD T�/l Phone: �� ��.��� 8'1�'� -.� Address/City/Zip:__�Y�?O � `� �t/�� �L fjl�d�'f/ �t-,,. �"l�f/� Pipelayer Training Certification Card#: or Master Plumber License#: I acknowledge that the information is complete and accurate and that the work will be in conformance with the ordinances and codes of the City of Eagan and the State of MN Statutes. I understand this is not a permit, but only an application for a permit, and work is not to start without a permit. �%t.�l�e•� E' �G�rc° „ _ _ �' 0 Applicant(Print Name) Applicant's Signature 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.orq