3688 Robin Lane Use BLUE or BLACK Ink
r
Ea Rail ForOfficeUse
4 City of Permit C
Permit Fee: 1(�� C,' tom'
3830 Pilot Knob Road
Eagan MN 55122 Date Received: C (k iC
Phone: (651) 675 -5675 Staff:
Fax: (651) 675 5694
2009 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: Cr Site Address: (7 Ak r l G? /,-r it
Tenant: 41 c;. <Gi a t�/ J ,J l Suite
RESIDENT OWNER Name: 1 /�_i'�'`A- 1 2 Phone: �'r
Add /City /Zip: c eg r
rr t2
Applicant is: Owner Contractor
TYPE OF WORK Description of work: c? 7
0 7 1
Construction Cost: 4' G) c) c'✓ Multi Family Building: (Yes No
CONTRACTOR Name: License
Address:
City: State: Zip:
Phone: Contact Person:
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.
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
accordan ce with the approved plan in the case of work which requires a review and approval of plans.
�i r>
Applicants Prin Name Applicant's Si ature
Page 1 of 3