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r <br />°c“f oiom <br />P.O.BOX <br />CRYSTAL BAY. MINNESOTA 55323 <br />(612)473-7357 <br />CITY PERMIT NO.8503 <br />Date__^>7 5/^ <br />Owner <br />G«ntri*etor <br />City License No <br />________________ State License No. <br />rhmakks anr special conritions <br />A.d,cs.,.?/^^^ Cqi^cap <br />PERMIT TYPE AND FEE: <br />Inside Plumbing (#tiyures—) <br />Water Meter (Si/e_^ g^i <br />Meter# .,^ V’ .W <br />Remote <br />Municipal Water Connection <br />Q Copper CL <br />□ new □ addition □ repair <br />Fee S--------------- <br />L.. s <br />Vlunicipal SevNcr Connection <br />Q pVC D Cast Cl <br />MWee S.\C Charge <br />On Site Septic S\stem <br />l ee S <br />Fee S <br />Water Well <br />Mechanical Equipment <br />Moving / Lilting Buildings <br />Land Alteration (Excavation, <br />Grading. Filling, etc.) <br />Fee S-- - <br />Fee S---- <br />Fee $ ■ <br />Fee S. <br />Fee S. <br />Fee S. <br />I ire <br />Sprinkler System (Fire) <br />Other:------------------ <br />Alter-the-fact Investigation <br />Fee S. <br />Fee S. <br />Fee $ <br />Fee $ <br />acknowledgement <br />Th» undrni«n»<l ‘*"**”' *^ ipeci»l intonnitton. <br />prrmll. Including wdtun •bo»«. Th« <br />condltton* p«n.lty of l.« <br />undcnlgncd ^JJfJTd In tcopt to lh« wo»k. <br />th*t Oil* pcnnlt * ,p,cin»d; U»*« diU pennit doct <br />activity Of dnptovciMnt W ,cti»IU«t ryquiftnf <br />not gnutt any ^ Uut permit do« not <br />..parau ponnit ol ».y City <br />pant authoiity U> vli^ „,uUUon. AU work thaU be <br />ordlnanee oi State aw. ordinances, budding <br />don. in stnet »*a *•“ "• <br />code. M.d/of health <*«*“*”*?' "^“uon by the City, <br />•ubtect to inapectlon. •^.V^denlgned agrees to cotiacl <br />rn^Tf^^t rou^’^'t?. be in vIoUUon o. the condfUon. ol <br />thu p»nml. <br />TOTAL <br />State Surcharge: <br />Total Amount Paid to City- <br />Fee S, <br />Fee S ‘75.^ <br />SifiiatuK ot Applicant , > y y <br />a- <br />Signature ol City-Off^al ^ . <br />( tule White l OeCory CanaO Intpetiof’* t't’PV <br />pmk I toiant^ t'»py Gold AppUc-tf. Raceipl