1861 Cliff Lake Ct Oct 07 2014 0826AM HP Fax page 13
Use BIUE or BLACK Ink
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� For Ottice Uae �
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Clty of�a�a� � Permit#: �
� Perm it Fee: � i�•� �
3830 Pllot Knob Road � �
Eagan MN 55122 � Date Received: �
Phone:(651)675-5675 I I
Fax:(651)675-5694 I Staff: I
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2014 RESIDENTIAL BUILDING PERMIT APPLICATION
Date� r'�'.� � Slte Address• 1�S� ! � � l, / '� l 3i ��G 5'G�,� �a,�� �
r unit�:
Name: �..7 i`'� ��'=::. ���'`�� f�: �''� v�,. Phone:
ResidenU
Owner Address/City!Zip:��9'Y!� C�
Applicant is: Owner �°`� Contractor --
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Description of work: � �° '.c,.� a�'�� --'1
Type of Wcrk I, :
Construction Cost: 3 ?S�'Z'�G. `..� Multi-Family Building: (Yes �/No_�
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Company,�'�%��;���u���'Z�2''�✓'���x�: Contact: !,'�,�.�yi.F,`;��;,,.<
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Contractor Address',����c@ v`r2� s��,.;-�; ��.� �:�r�.-����°��s�:.� city: �s��+��t�����,�
State��`���'° Zip: .�`� G • Phone:�.( •`j`'' �&'',�(�' )��Emell: ?t�.�G..'��' ' �f��°%' �
.�.,�;t�:T�tca .._.ra;^,�.�r}��s.�i. ';�„
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License#: ,�',���e�r�� r�i"l Lead Certiflcate#: •����� a-'`=�'"� ' f
If the project is exempt frorn lead certlflcation, please explain why: (see Page 3 for additional information)
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUiLDING
In the lasi 12 morrths,has the Clty ot Eagan i�sued 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:
Sewer&Water Contractor: Phone:
NOTE:P/ans and supportirtg documents thai you subm/t are considered fo be pub/ic intormation. Portlons of
the informatlon may be classJf/ed as non pubtic if you provide specific r+easons tfrat wou/d perm/f ihe City to
conc/ude fhat!he are trade secrets.
CALL BEFORE YOU DIG. Call Gopher State One Call at(651 454-0002 for rolection against underground utility damage. Call 48 hours
before you intend to dig to receive locates oi underground utilities. www. o hersta;eonecall ur
I hereby acknowledge that this information is complete and accurate; that the wo�k will be in canformance with the ordinances and codes ofthe 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; thet the work will be in
accordance with the approved plan in the case of work which requires a review and approval of plans.
Exterlor a-agthorized by a bullding permlt Issued tn accordance wNh the Minnesota State 8ullding Code must completed wlthln 180
da perml�suance. �,_,,...-----:-.:.°.�=
F�- ¢�! "�- `� � � '�f,�
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Applicant's Printed Name Applicant's Signature i
Page t ot 3