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4451 Lakeshoe Ter Use BLUE or BLACK Ink r----------------� I For Office Use � J • � Permit#:����� j �lt� 0� ���flIl - ' 1 ��� � � Permit Fee: 3830 Pilot Knob Road � � Eagan MN 55122 � Date Received: � Phone: (651)675-5675 I � Fax: (651)675-5694 I Staff: I � I 2015 RESIDENTIAL BUILDING PERMIT APPLICATION iL I�/�S' ��I s f ��L' �l�.o✓t✓ �.ai✓t�C� ��i,.�ptir. M� Unit#�. Date: Site Address: ��..x �.,_�.,�� �, � �°a�. �,.�,��,_ .���,. ,,.�,�.4.��-�.wo_,, ���e_�,_�..�.�y�a.x�,�..�.�,.�...�a,�.e � .�... - -.�,�..�..,._..,._ �..�.._m..� � __ . �� � Name: ��IY� ��(:�L s�!.o✓f.,,5 � Phone s � R�3Sid��'ifif � ����--�- s � O��"r, � Address/City/Zip: ; � i � Appiicant is: Owner Contractor �..,�.., �...�.,,�.�,.�.,..�,,�.�.,.�,,,..�,.�,.� .��,,��.��,..��..,,�� 3�..�..a�.µ�.�..._�.��....�,�,..�.,�.�..,,�.,,.�.6 �.. - � .�.�� ��,�� Description of work: �i✓�� C L � Construction Cost: Multi-Family Buiiding: (Yes /No� Y �H ..�.� m�,,� H�.,�..�,.w � . __ . ._._ _ �.,��...,m�,.,� ..�..�.�_,�...� �.��, .�, ...,.�...�..,�...,�. � � ���� �� � Company:�l�� �nf�+'� (�wl�G�1 �hc. Contact: �`�-s ��( �� �"" � � � �5a� �/'�.�bw�-� �� �U Su;�r '��i c�ty: �� �' � � � Contractor � Aaaress: _ � State:�Zip: gsy�� Phone: '7�3-�5� �vn"�� Emaii: ��J � �ot�tJ9,�i�u���r�c����� � � License#: �C ��� ��.� Lead Certificate#: ,..�w:�.��,�,..w.��.mM.�, .�.�. �.,,�wM.�. ,.�.�v,..,_.._�.�.w��,,�.�. .,, ,�w.�.�....M�.,.�..�....,�w_..,.,�,.�..�,.u�,.....�a.A.�..�.,�...».w.�,.�...,.�»..�..�..�.p.�,�..,.�,,.. 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 � Yes No If yes,date and address of master plan: � � � 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. 'C �.--•�--_-- X �u�f T roRc���,��,--� x b Applicant's Printed Name Appli s Sign ture Page 1 of 3