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I Use BLUE or BLACK Ink
I For Office Use I
' I
~ Permit
City of Ea[I~d I a(4d° S
Permit Fee: D I
3830 Pilot Knob Road I I
Eagan MN 55122 Date Received:
Phone: (651) 675-5675 I I
Fax: (651) 675-5694 I Staff:
I
2013 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: / I l 13 Site Address: 41~° LJ 1q4 Lf I~Le 4(q?f Unit#:
Name: Al Phone:
Resident/ v~ J F: ~`v1
4rn ~i~~f 2 z
Owner Address/ City/Zip: C ~ 'I`-'
Applicant is: Owner Contractor
Description of work: P. - 12~~
Type of Work ,
Construction Cost: 171 (e 60 Multi-Family Building: (Yes V/ /No
)
Company: c? Contact: J In^P~ 3 `E3 '3 ~_V
(off - 11a-q- to l l
Contractor Address: 0 City
State: r V~ Zip: Phone: _5C77~ Z( 777
License Lead Certificate
If the project is e empt from lead certification, please explain why: (see Page 3 for additional information) - V_ f
en L r; ~ l~ & \ red G~ 4t vv~ lz cal , 7 ,
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.gopherstateonecall.org
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. i
x A VY\ t 1 t r? Vv~
Applicant's P ' ted Name App 'cWSigature Pag
e 1 of 3