1855 Cliff Lake Ct Oct 07 2014 0825AM HP Fax page 10
Use BLUE or BLACK!nk
� For Ottice Use �
� j Permit ii: ��� j
Clty of E��aIl � � �
� Pertnrt Fee: �� �
3830 Pilot Knob Road
Eagan MN 55122 j Date Received: �
Phone:(651)675-5675 I I
Fex:(651)675-5694 I Staff: I
I I
. L���������.�������J
2014 RESIDENTIAL BUILDING PERMfT APPLICATION
� �
Date: �� �° � Si1e Address: � g�� l '�Y� ���� ��� 7 `-`�•'� '� � - �_
Jnit#:
J !. �[ a
Name: ��.���� ��=--- �r:,��?�''a� f':: ��. �'f-,. Phone:
Resident/
Owner Address 1 City!2ip; ' �� �-
Applicant is: Owner ��Contraclor ;
Description ot work: � � u-- -•- <�'La � �'"•v
Type of Work I � F�
Construction Cost: �7 �Z� / '� � Multi-Farnily Building: (Yes ��'� /No�
' �,• f'' r' f i` �..._ �
Company��. ° . �����u�i'�a� �'�.`7`I'���.-�s. Contact: 1`�����.��..� �-
Address:.�" � R `�'�=-< ya-.�-r.`�' �r+� �:�- C1�' �
COI1tf�C#O� -L l��� 1I � �!' , „�3..:.. City: ��f sl`�+%�,:a�
�r �'
, State!��`�'� Zip: �� �r� Phone: �a f?-��'s�'��� ��7 Email:�r`,4::.�.r�.�•n����;'�`�=,s9���c'''ra�;:��. "�
� �.^
License#: ��-��� 'r��.� Lead Certificate#: �'�''�°''��a�~'f�`""4''� - 1
If 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 Clty of Eagan Issued a permit for a slmllar plan based on a master plan?
_Yes _No If yes,date and address of master plan:
Licensed Plumber: Phone:
Mechanical Contractor: Phone:
Sewe�d�Water Contractor: Phone:
NOTE:P/ans and supportlrtg documents that you submlt are considered fo be pub/Ic lnformation. Pvrt/ons of
the/nformat/on may be classifled ss non-public if you provide specific reasons that wou/d permlt the City�o
conclude tha[the are trade secreis.
CALL BEFORE YOU DIG. Call Gopher State One Call at 651)464-0002 for protection against underground utilitydamage. CaU 48 hours
before you intend to dig to receive Iocale5 of underground utilities_ www. o herstat�onecall.or
I hereby acknowledge that this infocmation is complete and acwrate;thaf the work will be in confotmance with the ordinances and codes of the Clty of
Eagan; tha: I understand this is nol a permit, but only an application tor a permit, and work is not to start without a permit; that the work will be in
accordance wlth the approved plan in the case af work which requires a review and approval oi plans.
Exlerlor �horized by a bullding permlt lssued in accordance wlth the Mlnneeote S1ate BuIlding Code must�je completed wlthln 1 BO
da perm! ssuanca ��-°•
..
`�' '
-......� ,f°� `g . `r,�z
���,,; �
x ,.�.���`�-�- �_...�J./� �_•:�°' �"_,_.�, -..,. _ , �..�,:... 3r
x �---
Applicant's PriMed Name Appllcant's Signature ,
Page 1 of 3
Use BLUE or BLACK Ink
r--------^-------�
( For Office Use �
I � �� 1
C��TT o� j����� � Permit#: � � �
� i�
� Permit Fee: � �� �
3830 Pilot Knob Road � �
Eagan MN 55122 � Date Received: �
Phone: (651 j 675-5675 I �
Fax: (651)675-5694 I Staff: I
I �
2015 RESIDENTIAL BUILDING PERMIT APPLICAT�I� �SIZ�
Date: �Z ��1�S Site Address: � " `�s C�!�l� �,^� �ow�'1 ���" U t#:
�,.�.�...._,. � Name: ,., ���l�f'Y"� � ��m���.,�.,..�._.��.oi/(_,.5..�.e..,k�..�..�...a,,..d..u.�...a�., Phone: ��....�.....�.�.�.�.�.a,..�
� Ft�s�it��� � �
� Q���;r Address/City/Zip: �4�',
�
� Appiicant is: Owner Contractor
�,_ .,.�.,w..,�,. ...�. .,.�.d�.,.��m....�..p�,.n �..� ,.��w...�..,��._...,_.��.��..�..�...�.n..r...w.
��, ��_.�.��..w.e.;� �� .�
� Description of work: W ►'�
� T�� af V��ark �
� Construction Cost: Multi-Family Building: (Yes /No� �
�.. �,._,., .� �,.,..��, ,,��..w....�.�._��
� tl FO V � Company.�/,t�� �{?G�� ��G��1� �h�, Contact: ��-T �U( u� �
� � ��'^ ��� � �
� /� �i/ SUlT e
; Address: �S� �G���'� � �s� City:
Co�a�ract�r � �
� State:�Zip: SS��� Phone: '7�3-S,S�� .vn''�� Email: ��-� � /�Ja�?u���Y�clovJ.�
� � ,
� License# �G �O� ��.3 Lead Certificate#
���,���_�.,..��.�....�.w,_..��.�.....,�,�,.�,�,,,,..,.�..,,. �,._a. .���_.,rM._m�.�...�..�,�,�..��,�.�.,_.._ ,�,._,.,..�v......a��..��u�._,�...,..�..�_.,.�....m._�.,,�w�,..,��,.�..�.�..,���._ .,�...�,._.a
_ _ . . _ w
�
� If the project is exempt from lead certification, please explain why: �
� .�,.�....�.�.�.��za�. . ,Wx��.�.��... w_.d�.�.,..,�.�.�..����_�. .Y,.....�,�,�.,...,.eW�w,,.��..�.�,�.�...�. --��.�..�..�.�.,..�
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? g
�
� Yes No lf yes, date and address of master plan: �
t
i
� Licensed Plumber: Phone: �
Mechanical Contractor: Phone:
Sewer&Water Contractor: Phone:
Fire Suppression Contractor. Phone:
�� IV�Tf.F����s a�a�1 s�t��r��'��aEo����s�a�yFo�s�ab�a�e coa�s�ered t;�h���i�'ar�°t�, Pa�c�r��o�' j
� ��+i��or��rt���r�e classi�d as non pt���c�y�o��ro��ec�r��rs.t�a�t�v�1 per��t�re�tra�h �
�_ �.. co;n��fe f�M�f t� �.�e t�-ade sec�e�> , _�.
CALL BEFORE YOU DIG. Call Gopher State One Cafl at(651)454-0002 for protection against underground utility damage. Ca1148 hours
before you intend to dig to receive locates of underground utilities. www.aopherstateonecall.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 perrnit, 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.
Exterior work authorized by a building permit issued in accordance with the Minnesota S t Building Code must be completed within 180
days of permit issuance.
�/ �
X �Lf�f jyf.���t'°E'�a-�` x
6
Applicant's Printed Name Appli s Sign ture
Page 1 of 3