4269 Amber DrPERMIT #
PLUMBING PERMIT RECEIPT i1
CITY OF EAGAN
3830 PILOT KNOB ROAD, EAGAN, MN 55122 DATE:
CE: PHONE: 454-8100
Site Address
LOt /'/ - Block `- Se?ciSyb
l ?_, fL
? Name
-ia Address
!,? j 'j /
LE^?C=f ?
c ,
„
City Phone L'
, , , .
? Name
c Address
3
p -
City Phone
FEES
COMM/IND FEE - 1% OF CONTRACT FEE
APT. BLDGS = COMM RATE APPLIES
TOWNHOUSE & CONDO - RES. RATE APPLIES
MINIMUM - RESIDENTIAL FEE - $12.00
MINIMUM - COMM/IND FEE - $20.00
STATE SURCHARGE PER PERMIT - .50
(ADD $.50 S/C IF PERMIT PRICE GOES
BEYOND $1,000.00)
?
t.
SIGNATURE OF PERMIT`fEE
BLDG. TYPE WORK DESCRIPTION
Res. New
Mult. Add-on .?_
Comm. Repair '
Other
RES. PLBG. ONLY - COMPLETE THE FOLLOWING:
NO. FIXTURES TOTAL
Water Closet - $3.00 $
Bath Tubs - $3.00
Lavatory - S3.00
ShOwer - $3.00
KitChen Sink - $3.00
Urinal/Bidet - $3.00
Laundry Tray - $3.00
Floor Drains - $1.50
Water Heater - $1.50
Whiripool - $3.00
Gas Piping Outlets - $1.50
? (MINIMUM - 1 PER PERMIT) -
X Softener - $5 00
weu - $10.00
Private Disp. - $10.00
Rough Openings - $1.50
FEE:
STATE S/C:
CITY OF EAGAN GRAND TOTAL:
Receipt
MECHANICAL PERMIT
CITY OF EAGAN
Permit No.
Fee
Fill in numbered spaces S/C
Type or Print legibly Tot.
1. Date !- =• r2. Installation Cost
3. Job Address Lot Bik. Tract
4. Owner - 5. Contractor Phone
6. Address ?. ?l?, ?'.; ? ;?. s - ,•i?
7. City
8. Building Type: Residential ;?[1
9. Work Description: New O
10. Describe
State 'V' Zip
Commercial ? Institutional ?
Add-ji Alter Cl Repair ?
11.
Fuel Type
No. E.quioment 9TU - M. Ea.
Forced Air No. Equipment CFM
Ai
H
dli
Mfg. an
ng:
r
Boilers
Mfg. Mech. Exhaust
Unit Heater
Mfg.
Air Cond. - ' Other
Mfg. j
Gas, Piping Outlets
12. I hereby certify that the above information is true and correct, and I agree to
comply with all ordinances and codes governing this type of work.
Signed : for
Rough Final
Inspections: Date Insp. Date 7-3 ?r/nsp. ?GI
This is your permit when numbered and approved.
Approved CITY OF EAGAN 454-8700
CITY OF EAGAN
,,,,,,;.:,,_ Cedar Grove
, .
Owner i_ Street
v 11.'ul, ? i :, r; > ?
State EagansMN 55122
Improvement Date Amount Annual Years Payment Receipt Date
STREETSURF. MS 1985 1266.95 84.46 15 1266.95 C009308 8-13-84
STREET RESTOR.
GRADING
SAN SEW TRUNK
SEWER LATERAL ? 2 1 00 2.16 2 625.92 A 013693 3-27-84
WATERMAIN
WATER LATERAL 1 2
WATER AREA
STORM SEW TRK
STORM SEW LAT
CURB & GUTTER
SIDEWALK
STREET LIGHT
WATER CONN.
SUILDING PER,
SAC
PARK
CITY of EAGAN
BUILDING PERMIT
OWIIO[ .1.-I.WAR............ ?/•L?o-zzLr,?aOZ':2 ................"""""""'...."""'
Addreu (p=a.an:) .......
HuSlder? .....-19.-14'a-9-??-y...... CQ. ............--?-- ................................
Addreu ............:.'.........
-
0 iw
N4 3948
3785 Pilo! Knob Road
Eagan, Minaesola 55122
454-B100
Dals .?.-..z..'2.-l... (? .................
Btosiea To Be Ueed Fos Fson! Dsplh Heighf I Eel. Cos! srmi! Fee Remarks
?@ eo
..Y"l
....(l`:..../.. •??r.?.---.......... -------° ............................. Pez ..?Kr?:... .?./.?'.. .?Q.KlY.d..........---...................................
Mayor Sui1d?nQ Iaapaelos-1 ?Ix
This permit does not eulhorisa the use ot streels, roada, alleye or sidewalks aor does it give the owaer or hSs ageat
the xigh2 !o creale eny silualion whieh is s nuiaaaae oz whieh presenls a hmezd !o ffie heallh, saiely, ooaosaisace aad
geaeral welfare !o anpoae in the eommuoifp.
TFII3 PERMIT MUST BE pKEPT OqH THE PREMISE WAILE THE WORR IS IN PROGAESS.
This ie !o certify. 36el..yS?iGtY..t¢.F:.... 4 .:..............................has permiseion !o areet a..?. .. ..........................._upen
the abave described premise subjeci So the provisions of all applicable Ordinanees for !he Cifp oan.
Eagan Township
• Dakola Counlp. Minnesoia
Apglication foe Building Permit
Type of building or woxk coniemplaYed. Cizcle coxreci descrintions.
Resideniial Commercial Induslxial Ofher---------- .---------------------------------------------- ....
'_"_ - .__?r--
Euild Enlarge Aller Repair Install Move Wreck Oi:ier..........
?s
Dimensions--"-"--'---------------------------- Cost-------------------------"
Defails or remarks---- ?:.._......-'--------'---------------?---- ...............---------°-'----'---
Localion
PERMIT NO.
Dafe '- ----- if_._. .f??-./?s'7(
Number S4reei Beiween whaY cross sireefs Siso Esl. Valuation
???? ?
?a?2G
?233,ao
Lof Bloclc AdditPon Rearrangemen2 ar TracS
Owner __...__.!'"!_}_.._.?'!-p,i!?.'?."??._._._..-'__.'_"...._"_. Addrass ._._.?_`'`..!-..-------- ---------- ---- '"__.'..'_...._......__
---- -
Contracfor --<44!?'.:d-.:'_-lN-.................. .................... .. Address ...__l..°--------YtiP.------N^•-- -----------........ The undexsigned hereby makes apelicafion for a
permit to
? do work as herein apecif?ed, agreeing 2o do all worlc in sfrfici
Total fee collecied. accordanee wiYh ihe bssilding oxdinance adopied April 11, 1955
by the Eagan Township Soard of Supervisors.
Permi4 fees axe nat
refunda6le. ?
""'..... .... _. _'........_.....__ ...........------------ ............. _...... .....------- '.'
uigned
EAGAN TOWNSHIP
BUILDING PERMIT
oWne:?'??-"?
Address (pzesenf)
Builder -----_--'......
Address -_--.-_.....
DESCRIPTION
N°
Eagan Township
Town Hall
ne:a ?.....-... (/?--......
Sfories
? To Be Used For
?
? Fron1 Depih Heighi Est. CosS
? Permi! Fee Remarks
?
' ?1p
1lv? 9 j
/
LOCATION
or
Thi p i! does nof authorise the use of si:eefs, roads, alleys or sidewalks nor does ii give the owner or his ageni
the ' hf to creaie any silua2ion which is a nuisanee or which presenfs a hazard fo the health, safefy, aanvenience end
general welfa:e !o anyone in the communifp.
TFIIS PEAMIT MUST B.K PT 1 TH. -AE ISE W?IILE THE WORK IS IN PROG ES ?
This is !o cerfify, Sha2. !. y4FF'FC?has permission !o erec! . ....
?!'Y'1"?kL . ?. ,......upon
. . .
the above described premise subject !o the provisions of the BuildingOrdinance g n Town ... adopled April 11.
? /f/)
1955.
Chairman ot Town Board ing Inapectoz
Permit by
Legal Description
Lot
Blk
Add'n
Value ?
Type Const. X^-r^-? ?
5
SLAG
?By SUSSEL
?8y Owner Approx.
Dln
2-STARTINGS POINTS ONLY
, 5t ?6 'lo !s/t76- S.P.L.
S.S.P.L.
R. P. L.
Alley
?- J House
F. Stree
cl?l'4u:.F7Ther
WORKORDER
,i ??
NAME `? CM1J /'?? C7(cS ISO/j
r
J08 ADDRESS
BLDG CODE AREP
E 6,4 N
r.
HOME PHONE ?
BUS.PHONE:6 Y%"i fQjJ
SALESMAN ?- =' ?? " CONTRACT DATE SIZE
FOR OFFICF USE ONLY
CONTRACTOR 'JJOB'rf
DOOR SWING: ?j
H
OUTSIDE INSIDE
ERH H
? Squ2re With
? Rods
?9 Mesh
?SodRem.-By .:??'•??---,'?
? 5-Bag Mix
'lf6-6ag Mix
0 Tamping
0 No Tamping G A.B U. ChAJ',?' O
? QGrade Point
?Q'Condwt
? Blocks ? By Owner ? By Sussel
?Maintain 8' Total Wall
Height including Blocks
?Maintain 8' Wall Height on
Top of Biocks
?Other
?O H. Dr Offset
S D. Location
LJ Att Gar Roof Tie-in
Drawn on attached pictures
Existmg garage: No
? Detached ?Attazhed Yes ?
Size af exisUrg _- x
ExisUng garage will be:
? Left as is
? Converted to LS. - ey owner
? Remaved By: Owner i.1
Sussel I-1
jJunk Musi Be Removed !3y Ownerl
0 Specify removals by Sussel
or owner - trees, bushes, etc.
? Show approx dist garage to
house and all prop. lines
Stakes visi6le - L1 Yes 5? No
SurveY available -' l Yes !; No
? Special instructions from
owner'
; -7L i
J
MASTER CARD
ON
OWNER
STRUCTURE AND
LAND USED AS
Permit
No.
Issued Issued To
Confractor Owner
BUILDING
PLUMBING
CESSPOOL - SEPTIC TANK
WELL
ELECTRICAL
HEAiING
GAS INSTALLING I
SANITARY SEWER
OiHER
OTHER
Items Approved
(Initial)
Date
Remarks
Distance From Well
FOOTING SEPTIC
fOUNDATION CESSPOOL
FflAMING TILE FIELD FT
F I NAL
ELECTRICAL
HEATING DEPTH
OF WELL
GAS INSTALLATION
SEPTIC TANK
CESSPOOL
DRAINFIELD
PLUMBING
WELL
SANITARV SEWER
Violations Noted
on Back
COMMENTS.
COMPLIANCE INSPECTION REPORTS
TO 6E USED ONLY IN EVENT OP OBSERVED VIOLATIONS
PERMIT NO.
CONDITIONS OF CON5TRUCTION AT THIS INSPECTION
NO EVIDENCE OP NON-COMPLIANCE
06SERVED.
? ACCEPTABLE SUBSTITUTIONS OR
DEVIATIONS.
DATE OF INSPECTION
? NON-COMPLIANCE. BUIIDER WILL COMPLY
WITHOUT DELAY.
ITEMIZFD AND DESCRIBED AS
NON-COMPLIANCE. BUILDER DOES NOT
INiEND TO COMPLY.
? COMPLETION OF CERTAIN IMPROVEMENTS
WILL BE DELAYED BY CONDMONS BEYOND
CONTROL.
? REINSPECTION REQUIRED DATE OF REINSPECTION
REINSPECTION REVEAIED
CERTI FICATION - I certify that 1 have carefully inspected the above in which I have no interest present or prospective, and that I have raported herein
all significant conditions oLServed to be at variance with ordinances af xhe Town of Eagan, approved plans and specifications, and anY SPecific reyuire-
ments for off-site improvements relating to the property inspected.
? ALL IMPROVEMENTS ACCEPTABLY COMPLETED
DATE
s.
2004 RESIDENTIAL BUILDING PERMIT APPLICATION
lI1 ?J?a? City Of Eagan
3830 Pilot I{uob Road, Eagan MN 55122
Telephone # 651-675-5675 FAX # 651-675-5694
?1d?Doo
New ConsW ction Reauirements RemadeVReoair Reauirements Ofice Uu Onlv
3 registe2d site surveys showirg sq. ft of lot, sq ft. of house, and all roofed areas 2 copies o( plan CeiY of Stwey Recd Y_ N
(20% maximum lot coverage allowed) 1 set of Eneigy Calculations for heeted addPoons 7rC8 Pres.P.(aa Recd °-,.;,,Y, ?t?
2 copies of plan showing heam & window sizes; poured found design, etc 1 site survey for additions & decks T rae Pfe€$equlf8d It Y=N
lserotEnergyCalculations Add'N'on-indkafe'rfon-sifesepUcsystem OnsdeSePtic$ystem'_Y__N
3 copies of Tree Preserva6on Plan if lol pWtted aNer 71153
Rim Joist DeWil OpUons selechon sheet (bldgs wAh 3 or less uni4s
Date 3 / // 0 J' Construc[ion Cost ? /
Site Address
? Unit/Ste #
Description of Work
Multi-Family Bldg _ Yol
CS Fireplace(s) _ 0_ 1 _ 2
Own
r
P
t hone # ( (PJ? 7 ?°? ? / ?
Tele
roper
y
e p
Contractor
Address ABC Seamless City
State
,,,,,N
nnnie 56068 (??
Zip Telephone #(?J? 8 U ? ?
?-3
4??K o
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
- Minnesota Rules 7670 Cateeorv 1 Minnesota Rules 7672
Energy Code Category . Residential Venlilation Category 1 Worksheet • New Energy Code Worksheet
(4 submission lype) Submitted Submitted
• Energy Envelope Calculations Submitted
Have you previously constructed a building in Eagan with a similar plan2 _ Y
fee applies.
Licensed Plumber
Mechanical Contractor
Sewer/Water Contractor
Telephone #
,
Telephone #('I ?
Telephone #
N If so, 25% plan review
I hereby apply for a Residential Building Permit and acknowledge that the inform-ati-ori is-campiete-and-laccurate;
that the work will be in conformance with the ordinances and codes of the City of Eagan and the State of MN
Statutes; 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 accardance with the approved plan in the case of work which requires a review and
approval of plans.
Jme /1(e
Applicant's Printed Name App i ant's Signature
OFFICE USE ONLY
Sub Types
? 01 Foundation ? 07 05-plex ? 13 16-plex ? 20 Pool
--?(-02 SF Dwelling ? 08 06-plex ? 16 Fireplace ? 21 Porch (3-sea.)
? 03 01 of _ plex ? 09 07-plex ? 17 Garage ? 22 Porch/Addn. (4-sea.)
? 04 02•plex ? 10 OS-plex ? 18 Deck ? 23 Porch (screen/gazebo)
? 05 03-plex ? 11 10-plex ? 19 Lower Level ? 24 Storm Damage
? 06 04-plex ? 12 12-plex Pibg_Y or _ N ? 25 Misceilaneous
Work Types
? 31 New ? 35 Int Improvement ? 38 Demolish Interior
I? 44
? 32 Addition
? 36
Move Building ? V?
42 Demolish Foundation ? 45
? 33 Alteration ? 37 Demolish Building' ? 43 Reroof ? 46
? 34 ReplaCement •Demolition (Entire Bldg) - G iva PCA handout !o applicant
Valuation Occupancy MCES System
Census Code Zoning City Water _
SAC Units Stories Booster Pump _
# of Units Sq. Ft. PRV _
# of Bldgs Length Fire Sprinklered _
Type of Const Width
_ Footings (new bldg)
_ Footings (deck) ?
_ Footings(addition)
Foundation
Drain Tile
Roof Ice & Water Final
_ Framing
_ Fireplace _ R.I. _ Air Test _ Final
_ Insulation
REQUIRED INSPECTIONS
Final/C.O.
FinaUNo C.O.
_ Plumbing
HVAC
Other
_ Pool _ Ftgs _ Air/Gas Tests Final
_ Siding _ Stucco _ Stone _ Brick
_ Windows
_ Retaining Wall
Approved By: , Building Inspector
Base Fee
Surcharge
Plan Review
MC/ES SAC
Ciry SAC
Utility Connection Charge
S&W Permit & Surcharge
Treatment Plant
License Search
Copies ?
Other
T
t
l ?
o
a
? 30 Accessory Bldg
? 31 EM. Alt - Multi
? 33 EM. Ait - SF
? 36 Multi Misc.
Siding
Fire Repair
WindowslDoors
City of Eagan
3830 Pilot Knob Rd
Eagan, MN 55122
(651) 675 -5675
www.ci.eagan.mn.us
Site Address: 4269 Amber Dr
Lot: 14 Block: 7 Addition: Cedar Grove 2nd
PID:10- 16701 - 140 -07
Use:
Description:
Sub Type: e- Reroof
Work Type: Replace
Description: House & Garage
Census Code: 434 -
Zoning:
Square Feet: 0
Comments: If there is no ice protection inspec
acceptable in lieu of inspections.
Fee Summary:
Valuation: 3,000.00
Contractor:
Apex Roofing & Siding
944 Oriole Dr
Apple Valley MN 55124 -0000
(952) 891 -1919
BL - Base Fee $3K
Surcharge - Based on Valuation $3K
Total:
Applicant/Permitee: Signature
PERMIT
City of Eaan
- Applicant -
Construction Type:
Occupancy:
on prior to final, you must meet inspector with ladder and flat bar. Pictures are not
Owner:
Jacob N Griemann
4269 Amber Dr
Eagan MN 55122 -2058
Permit Type:
Permit Number:
Date Issued:
Permit Category:
$88.50 0801.4085
$1.50 9001.2195
$90.00
Building
EA084013
07/03/2008
ePermit
I hereby acknowledge that I have read this application and state that the informa
of Minnesota Statutes and City of Eagan Ordinances.
on is correct and agree to comply
h all applicable State
Issued By: Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA115984
Date Issued:10/01/2013
Permit Category:ePermit
Site Address: 4269 Amber Dr
Lot:14 Block: 7 Addition: Cedar Grove 2nd
PID:10-16701-07-140
Use:
Description:
Sub Type:Reroof
Work Type:Replace
Description:
Census Code:434 -
Zoning:
Square Feet:0
Occupancy:
Construction Type:
Comments:If there is no ice protection inspection prior to final, the contractor must meet the inspector w/ a ladder and flat bar.
Pictures are not acceptable in lieu of inspections.
Carbon monoxide detectors are required by law in ALL single family homes .
Kathleen Myrman
Fee Summary:BL - Base Fee $4K $103.25 0801.4085
Surcharge - Based on Valuation $4K $2.00 9001.2195
$105.25 Total:
I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State
of Minnesota Statutes and City of Eagan Ordinances.
Contractor:Owner:- Applicant -
Jacob N Griemann
4269 Amber Dr
Eagan MN 55122--205
Apex Roofing & Siding
944 Oriole Dr
Apple Valley MN 55124-0000
(952) 891-1919
Applicant/Permitee: Signature Issued By: Signature
Date:
City of kap
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
RECEIVED
APR. 2 5 2014
Use BLUE or BLACK Ink
For Office Use
ty
it
Permit #:
Permit Fee:
Date Received:
Staff:
2014 RESIDENTIAL BUILDING PERMIT APPLICATION
5/(/ 11 Site Address: LONt' 4M V L� D%l;ve
Resident/
Owner
Name:
JKQ �
Address / City / Zip: q_ ,1„ r
Unit #:
Phone: 67/4 7 o . ‘L/57
E-oteto
Applicant is: Owner (7 --Contractor
Description of work: —114.1- t I / £91'Z S'y tiA ✓J d 1�
Construction Cost:
aco oa
Multi -Family Building: (Yes / No
Company: E9/e Sr i&y eric&S,I LL69 Contact: 7,
Address: //30 Ad/Ori //" 1)(111' City: 4/10UOCk
State: /141\i 1\i Zip: 55 3bq Phone: I ; /) '70.3 "" 7 3 5-f
License #: 13G‘ 7 ? t7 7 7 Lead Certificate #:
If the project is exempt from lead certification, please explain why: (see Page 3 for additional information)
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:
Licensed Plumber: Phone:
Mechanical Contractor: Phone:
Sewer & Water Contractor: Phone:
NOTE: Plans and supporting documents that you submit are considered to be public information. Portions of
the information may be classified as non-public if you provide specific reasons that would permit the City to
conclude that they are trade secrets.
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 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 State Building Code must be completed within 180
days of permit issuance.
x Z4 pry. ijCcoo
Applicant's Printed Name
x
Appli nt's Signature
Page 1 of 3
A-111Or\ /o 2y
DO NOT WRITE BELOW THIS LINE
SUB TYPES
Foundation Fireplace
Single Family Garage
Multi Deck
01 of _ Plex Lower Level
WORK TYPES
New
Addition
Alteration
Replace
Retaining Wall
DESCRIPTION
Valuation
Plan Review
(25%_ 100%_)
Census Code
#of Units
# of Buildings
Type of Construction
Interior Improvement
Move Building
Fire Repair
Repair
0
1( `2
REQUIRED INSPECTIONS
Footings (New Building)
Footings (Deck)
Footings (Addition)
Foundation
Roof: _Ice & Water Final
y. Framing
Porch (3 -Season) Exterior Alteration (Single Family)
Porch (4 -Season) Exterior Alteration (Multi)
Porch (Screen/Gazebo/Pergola) Miscellaneous
Pool
Occupancy
Code Edition
Zoning
Stories
Square Feet
Length
Width
Fireplace: _Rough In _Air Test _Final
Insulation
Sheathing
Sheetrock
Fire Walls
Braced Walls
Reviewed By:
Accessory Building
Siding Demolish Building*
Reroof Demolish Interior
Windows Demolish Foundation
/` Egress Window Water Damage
*Demolition of entire building — give PCA handout to applicant
Meter Size:
MCES System
SAC Units
City Water
Booster Pump
PRV
Fire Sprinklers
Final / C.O. Required
)' Final / No C.O. Required
HVAC Gas Service Test
Gas Line Air Test
Pool: _Footings _Air/Gas Tests _Final
Drain Tile
Siding: _Stucco Lath _Stone Lath _Brick
Windows (5,4‘. j.
Retaining Wall: _ Footings _ Backfill _ Final
Radon Control
Erosion Control
Other:
Building Inspector
RESIDENTIAL FEES
Base Fee
Surcharge
Plan Review
MCES SAC
City SAC
Utility Connection Charge
S&W Permit & Surcharge
Treatment Plant
Copies
TOTAL
Page 2 of 3
Use BLUE or BLACK Ink
� r————————————————�
I For Office Use z � �
I �
� � Permit#: � � I
City of �a a� � �-- �
� I Permit Fee: �
3830 Pilot Knob Road � I
Eagan MN 55122 � Date Received: I
Phone: (651) 675-5675 � �
� Staff: �
Fax: (651)675-5694 �_________________i
2015 RESIDENTIAL PLUMBING PERMIT APPLICATION
Date: ��e �J. �� Site Address:��� � 1M� �, ����.��/r ,���"/ /�
Tenant: Suite#:
� w ;(� � ���III�i��e ; Name: l,/1� //��� Phone:�7/�<�/Pc -����
�i���� ���p _�i�!����'�'� y p: � 7 �/��Y10 �(//�
' Address/Cit /Zi �° %����
� k� � �
�� r � ���}y��
,p /� , � / �J
�r� �� "�� � Name:�/- �(��`i�t l� �i�� � License#: l����l�l�,�
� ���
�� ��.� ��s � _ /�'� J��
� �' 7 �� 7�r� �-�G�� y: Lv�d�lL� �
' �� � �' � ������ Address: Cit
�� � ��� ��
��� � �� � �� �
State:�� ��Zip: � � Phone:
�rd������ ,E� � �
� � '��. ��"� Contact: ��✓� Email:
�a����mw���:�,��yi��� ���-:
�a� New �Replacement _Repair _Rebuild _Modify Space Work in R.O.W.
����?�3'��L?l'�( — —
�
� i ��� , � �
�,���.����,� � ��,��,�'�i�� �1�j��� Description of work:
= � -- -- -�:''. RESIDENTIAL
= �Water Heater
�`"� Water Softener
�` Lawn Irrigation�RPZ/_PVB)
�� �������� � � Add Plumbing Fixtures�Main/_Lower Level)
��� -.: �� ��N ����� Septic System
� � New Water Turnaround
�, 3 :: � —
(�j ��iq '°��� �7�ii's Abandonment
RESIDENTIAL FEES:
$60.00 Water Heater, Water Softener, or Water Heater and Softener(includes$5.00 State Surcharge)
$60.00 Lawn Irrigation (includes$5.00 minimum State Surcharge)
$60.00 Add Plumbing Fixtures, Septic System Abandonment, Water Turnaround*(includes$5.0o State Surcharge)
"'Water Turnaround (add$210.00 if a 5/8"meter is required)
$175.00 SeptiC System New($10.00 per as built) (includes County fee and$5.00 State Surcharge)
TOTAL FEES$
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.aopherstateonecall.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.
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