4487 Lakeshore Ter Use BLUE or BLACK Ink
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I For Office Use �
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Permit#: �
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J 0 �� I 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: �L I�/�S Site Address: ��� (/����`r�` ` ;�''��' � ���� ��� Unit#:
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' � Name: u �� .���'`�� Phone: �
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� Qy��;r � Address/City/Zip: �� . �
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Applicant is: Owner Contractor
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� ��� ,� Description of work: W�+'z� C�
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€ � Construction Cost: Multi-Family Buiiding: (Yes /No� �
�dw � Company:lJt��' M��h.fi�� L.�''��t�.G�d 1� �h�. Contact: �/..l �"�'� ua� �_�__, .�,��.�
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� Address: V G1� ��� �s� City: � �
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� State:�Zip: �Sy�� Phone: '7G3-S.S� .Gn'lJ Email: �°�� � �w�.Irl�au���1''��°Yf.
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� License# �G �d� 7��3 l.ead Certificate#
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` If the project is exempt from lead certification, please explain why:
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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? �
�
� Yes No If yes, date and address of master plan: �
i �
� Licensed Plumber: Phone: �
Mechanical Contractor: Phone:
Sewer&Water Contractor: Phone:
Fire Suppression Contractor: Phone:
�1V�JTE.P�ar��a�d��r�pont���r d:ocu�a�:r��s that you�c���#��e c��s�tl�retl t�o be p��i�rr��rt#cr�. Pa�r��o� �
t��i���rma�n r�ay be ciass��ed a�non pt��i��r'f y�t�prorr�Re�pec��fc rea�o�s tfia#w�,�t��err��#�h�'Ci�t� �
con�f�de th��i�e �re f�a�e�c��.
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. www.qopherstateonecall.orq ,
i hereby acknowledge that this information is complete and accurate;that the work wili be in conformance with the ordinances and codes of the City of '�
Eagan; that 1 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.
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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ApplicanYs Printed Name Appli s Sign ture
Page 1 of 3
Use BLUE or BLACK Ink
r---------^------�
I For Office Use �
� �L �/� I
� Permit#: u �
Clt� of ����� � �; �
� Permit Fee: ��� �
3830 Pilot Knob Road � �
Eagan MN 55122 � Date Received: �
Phone: (651)675-5675 I �
Fax: (651)675-5694 � Staff: I
I �
2015 RESIDE���Al��6UILDING PERMIT APPLICATION�z �
;� �s I r EJ`' N �rx.�� �'!oY� �v�'a C,�-- �' a/'a
Date: Site Address: e.1� � Unit#:
� � ��Name��u n /��!"� �e���� .v���/'��' ,.�...a.�.��_�,.,.,.�...�..�,.� Phone:��.�.,�..�,�w ...�.ow. ��
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� QWi��I' � Address/City/Zip: ��� � y��� L�1 < ocr �-t6dr2 cz !.� c�-. ;J .�S�Z� a
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� � Applicant is: Owner Contractor
��Description of work: J����.�.�..,.,�a.._Q,.,��,wu.���,.��...�.w. . u ��.��.��,,.._.�.r��.�.�....,�.�..,�......�
Typ�e a#v�lo�k � �
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� �� Construction Cost: / � �' �� Multi-Family Building: (Yes /No� �
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� � Company: Cr fS ����0� L"""��`�O 1 ��nc. Contact: ���S � 9�
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� Address: ✓�� ��`55�'Ld l�t, G 1` ss� Cify: �'�,�'/�� � �
CQl�#t'1Ct=O�' � 1 �
� State:�Zip: �-�y�� Phone:��3-'�.56-0�11,/� Email: L��"�1G��Gf��(�'s../`�G��'��,
' �, �
License# ��v 6 G�7 /3 Lead Certificate#
' If the project is exempt from lead certification, please explain why:
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? �
,
S
d
Yes No If yes,date and address of master plan: �
�
� Licensed Plumber: Phone: �
� Mechanical Contractor: Phone: �
�
� Sewer&Water Contractor: Phone: �
Fire Suppression Contractor: Phone:
NOT�':#��a�s a�ad�p�o����docur�e�ts tha#pa�r s�br��t�'e co�s�d�retl!r�b��rb�c i��r��`�an. Pa�o��o�'
t�Q�nt'�rt�a��on����e ctassi�sd�s�c�n p�b��i�'y��pro��ls�pec��+c r�asr����at t�oc���t pe►r�t��C�to'
sr>
� ca��de t�aat� a�e�ra�le,�ec�s, % �
CALL BEFORE YOU DIG. Call Gopher State One Calf at(657)454-0002 for protection against underground utility damage. Call 48 hours
before you intend to dig to receive locates of underground utilities. www.popherstateonecall.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 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.
Exterior work authorized by a building permit issued in accordance with the Minnesota S e uilding Code must be completed within 180
days of permit issuance.
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Applicant's Printed Name App c s Si ature
Page 1 of 3