1850 Cliff Lake Ct Oct 07 2014 0823AM HP Fax page 4
Use BLUE or BLACK Ink
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� For attice Use �
� j Permit#: l��lQ V`f' j
Clty af �a�a� � .r�— �� �
� Permit Fes; J �,�� �
3630 Pllot Knob Road
Eagan MN 55122 � Date Received �
Phone:(651)675-5675 � �
FaX:(651)675-5694 I Staff: I
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2014 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: A�13P� �.' � Site/+ddress:��� � � �. 1��!I�St1 ��`� ��� `-')
�_ �����n:
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Name: ��0�- , �'���-`-=�• �L��� �; �. �� Phone:
Resident/
Owner Address/City/2ip: ' �i g'7Y7�
Applicanl is: Owner �F�'���Contractor
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Type of Work Description of work: �- � �, �
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Construction Cost; 5 � Multi-Family Building: (Yes �''�/No_�
Company;,�°'`H " �'r`-� �;1��"-.�c�,�t,a�'1����;Z�''�da�c;s�:� Contaci: �w �:�7�e,r-�•:�..-.,-.
ContraCtOr Address:�'� ` Oo'a���d�,;�: `.av" :^ ;�.�'�� City: �f�1'�-''J r.��
State���'��,F Zip: �')�'• ��I Phone: � P`����� ��,�Email: aa%�;��..��.`��r.�`c°�rF .'� ���.�f�-
�icense tt: t=r�.= �'��'?�'�'�`,� Lead Cehificate#: �'�f�=��`-�>-�'-i� � �
If the project is exempt from lead certlfication, please explain why: (see Page 3 for additional information)
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
In the last t 2 months,has the Clty ot Eagen iasued a permlt tor a similar plen 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:P/ans and support/r�g document9 that you submit are cons/dered to be public informaflon. Pprtions of
the intormatlon may be classified as non pub/ic ff you provlde spec/f!c reasons that would pe�mlt the Clty to
conclude that the are trade secrets..
CALL BEFORE YOU DIG. Call Gopher State One Call at 651 454•0002 for rotection against underground utilify damage. Ca1148 hours
before you intend to dig to receive locates of underground utilities. v:tivw. o herstat�cnecall.oc
I hereby acknowledge that this information is complete and accurate; that lhe work will be in conformance with the ordinances and codes of the Clty of
Eagan; Ihat 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.
Exterlor�horized by a bullding permlt iasued In accordance with the Minnesota State Building Code must be completed wlthln 180
, day�"�perm ssuance. ,._„_..Y---�-�-°�,w-'"T'°
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Appllcant's Printed Name ApplicanYs Sienalure „
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