4451 Lakeshoe Ter Use BLUE or BLACK Ink
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� Permit Fee:
3830 Pilot Knob Road � �
Eagan MN 55122 � Date Received: �
Phone: (651)675-5675 I �
Fax: (651)675-5694 I Staff: I
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2015 RESIDENTIAL BUILDING PERMIT APPLICATION
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Date: Site Address:
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�� � Name: ��IY� ��(:�L s�!.o✓f.,,5 � Phone s
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� Appiicant is: Owner Contractor
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.�.�� ��,�� Description of work: �i✓�� C L
� Construction Cost: Multi-Family Buiiding: (Yes /No� Y
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� Company:�l�� �nf�+'� (�wl�G�1 �hc. Contact: �`�-s ��( �� �"" �
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� Contractor � Aaaress: _
� State:�Zip: gsy�� Phone: '7�3-�5� �vn"�� Emaii: ��J � �ot�tJ9,�i�u���r�c�����
� � License#: �C ��� ��.� Lead Certificate#:
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a If the project is exempt from lead certification, please explain why:
COMPLETE THIS AREA ONLY IF CONSTRUCTWG 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? i
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Yes No If yes,date and address of master plan: �
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� Licensed Plumber: Phone: �
Mechanical Contractor: Phone:
Sewer&Water Contractor: Phone:
Fire Suppression Contractor: Phone:
: IV�TE':P��fiS 1�C�SiJ�/70/�l�i�C�AGI��@;fiJ�'�f/]8�,)/O�1&U�J�1`#��'�CO�t.S�t�it'8t��O�w�/�C��0!'p�ft'�`�tl�i. P��ons o#' �
� t��%nforma�an r�ay be cl�ss��ed as n.on p�a�il�� �F yv�prvv�ate s�ec�i�c r�as�r�s t�a#�!d p8rr��t t�C��y t�
cor�cl�de t���e �re t�a�te secr�s. ��
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. wwvv.qopherstateonecall.orq
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 noi 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.
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.
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Applicant's Printed Name Appli s Sign ture
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