Untitled _ Use BLUE or BLACK Ink
For Office Use I
04 O}'Eale Permit#:I Permit Fee: �`0 ` �t j
3830 Pilot Knob Road i I
Eagan MN 55122 I
Phone:(651)675.5675 I Date Received:
Fax:(651)675-5694 I I
Staff:
2016 MECHANICAL PERMIT APPLICATION
❑ Please submit two(2)sets of plans with all commercial applications.
Date: Site Address: u) &oI jr n TI 1 I 1 TC y ra cc
Tenant: /) Suite M q q
Name: ~~n Phone:
Address/City/Zip: CA (An 5S12-2—
Name: hilt flbtAr License#: V1 a U1 1 Ey )
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Address:-190q
Va m 1 I I VS City: ash n(A
� State:J I IV Zip: 'J'J U Phone:
Contact: Email: ' YV i OS.0 O
New Replacement Additional Alteration Demolition
Description of work:
SIM
RESIDENTIAL COMMERCIAL
Furnace _New Construction _Interior Improvement
Air Conditioner _Install Piping _Processed
x � . ,� �g —Air Exchanger _Gas _Exterior HVAC Unit
Heat Pump _Under/Above ground Tank (_install/_Remove)
Other
RESIDENTIAL FEES
$60.00 Minimum Add or alteration to an existing unit,includes State Surcharge ' n
$100.00 Residential New, includes State Surcharge =$ Vc TOTAL FEE
COMMERCIAL FEES Contract Value$ X.011
$60.00 Permit Fee Minimum
$70.00 Underground tank installation/removal =$ Permit Fee
Surcharge=Contract Value x$0.0005 =$ Surcharge
If the project valuation is over$1 million,please call for Surcharge =$ TOTAL FEE
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.
x Vasse4A Ma Khc l 1 x JAA k5LYA
Applicant's Printed Name Applicant's Sign
FOR OFFICE USE
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Underground ilaugh In Air`'fst Ges Serv�Oe hest` indoor He�it;, HVAC 5txeentng