842 Ivy Lane - COCCity of Evan
SANITARY SEWER SYSTEM
CERTIFICATE OF COMPLIANCE for
INFLOW & INFILTRATION
City of Eagan, Minnesota
Property Address:C{i2
COi'IPLIANCE WITH INITIAL INSPECTION
41,11` City of Baan
his is to certify that the property listed above has been inspected by authorized City personnel on , 201 a
and found to be in compliance with Section 3.40 of the City Code and no corrective work was required.
COMPLIANCE AF TER CORRECTIVE WORK PERFORMED
This is to certify that the property listed above has been found to be in compliance with Section 3.40 of the City Code
after satisfactorily completing the required corrective repair work under (check all that apply):
n City Sanitary Sewer Permit n City Plumbing Permit
NOTE: Applicable only if box is checked: 2Based on a review of the Sewer Service video inspection/report on file, it is
recommended that periodic cleaning or future inspections be perfor ilefl to minimize a otential blockage due to:
Grease Build-up, Root Intrusion, Dip/Settlement in Pipe, Other :.(.i(kra G"C �� -' L�
City Approved:A`-
Print name
White Copy: Property Owner
PVV\ 1 Z7 C.— T i !! 5 1 C F C
Date
Signature
Yellow Copy: City ot Eagan (Parcel File)
rev 2 23.2010
11/01/2012 12:20 Les Jones Roofing, Inc. (FAX)9528817009 P.0061006
41' City of Eagan
Date:
3830 Pilot Knob Road
Eagan MN 66122
Phone: (651) 675-5676
Fax: (661) 675-5694
4024101
Use BLUE or BLACK Ink
For Office Use
Permit* //e 7 9a 7
/2���
Permit Fee:
Data Received:
Staff.
2012 RESIDENTIAL BUILDING PERMIT APPLICATION
11 lr 112
J
Site Address': 8NIVY 1,41JE Unit#:
RESIDENT /
OWNER
Name: 96 ACT M14N Ata€MIrIJT Phone: 763 -- Z31- 69/9
Address / City / Zip: 81 D DECATUR. ME Al 4I 2 4 Crab 3J Atte/ 5s'k7,7
Applicant is: Owner X Contractor
TYPE OF WORK
Description of work: REMOVE' A -ND REA.AC ROOF (Yz of ROOF
Construction Cost i- ID 0 d r Multi-Femlly Building: (Yes / No
QONTRAOfiOR
Company: L E ft) M ES F t tKoNG Contact Cf(R tS ANDER Sal
Addrese: q 1 14i. iio" vTTZE"ar city: Bj DoMWCrrbnl
State: $ Ni Zip: 5S 4tb Phone: 'U1— gg I — 22* 1
License #: 4560 x/31 113 Lead Certificate #: NAT- 407}121 Sivril e
If the project Is exempt
from lead certification, please explain why: (see Page 3 for additional information)
In the last 12 months,
Yes If
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
has the City of Eagan Issued a permit for a similar plan based on a master plan?
yes, date and address of master plan:
_No
Licensed Plumber:
Mechanical Contractor:
Sewer & Water Contractor:
Phone:
Phone:
Phone:
nfomE: Plans andeufrparling.d6curinirrls thai ou subnlrR areionside►aadt&beod iih4 6rrna'lfbn. Porfions,of
fhednformat/ontmay-be•elassified`aswnon-public..if you provfde.specltIc reasons'thatnwouldrpernrltthe•Clty to
FAncl!tig ftt8f..�!py-ftre°I 4de•4%•
CALL BEPOlRE ¥OU pIGC. CaII Gopher State One CaII at (651) 454.0002 for protection against underground utility damage. Call 46 hours
before you Intend to dug to receive locates of underground uUlltlee. ywwv.agpjierstateonecall_org
I hereby acknowledge that this Information Is complete and accurate; that the work wtit 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.
Exteriorwork 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 Cilia.0 Ai _0
Applicant's Printed Name
Applicant's Signature
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