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. OFFICE STAFF FOR OFFICE USE ONLY <br /> PLACE SIGNED ORIGINIAL IN - <br /> � Building Permit PERMIT FOLDER Amount Due: $ '69) <br /> .16.0.161M'x»« CITY OF LONG LAKE I VI <br /> Da�te Paid: M I <br /> 450 Virginia Avenue, PO Box 606 CCO NGUPRO PROPERTY FILE OFFICIAL,ILDING Check# <br /> Long Lake, MN 55356 Cash Receipt# <br /> C I T Y 0 F Phone/ 952.473.6961 �� ��� LOC/ Bond(s) Required? <br /> 211QLONG LAKE Permit #B ('�. - t J [ ]Yes [ No <br /> D -J Date Posted: <br /> + <br /> X BuildingOfficial / Staff Signature � <br /> Date Issued l'i Zl L f i <br /> COMMENTS <br /> Special Approval [ ] Planning/Zoning— Planning Case No. [ ] Fire Department—Staff Initials <br /> [ ] Engineering—Staff Initials [ ] Public Works Department—Staff Initials <br /> . ** PERMIT HOLDER: TO SCHEDULE INSPECTIONS,PLEASE CALL METRO WEST INSPECTION SERVICES AT 763.479.1720** <br /> Site Information <br /> Site Address (INCLUDE SUITE#) sass— ©LI 1.r 4' +>Li (I - iOI 3O Property ID# <br /> clA i2 aiioN6C7 0&.3 7vDl le/n , 4 LCC C E <br /> Permit Request—INCOMPLETE APPLICATION WILL NOT BE ACCEPTED <br /> Owner Information Contractor Information <br /> Name Name g.61:?p-i4V I , )OLA kln{-{cLz, t\ ifl :S <br /> Address Address 222(110 01),E) 12,1—V--) <br /> City/State/Zip City/State/Zip TUU t Ll - , 13 cso 'f 4 <br /> PhonePhone qP ..a. ----.67/ License # <br /> Project PROJECT VALUATION $ /\-')/Ct Estimated Completion Date 01A <br /> Information COMPLETE Description of Work &O - COk I CJ770&L i/('!LItf'2i iiLOSS <br /> /2-69126 RP-- 0/2-0/U0 `?)2,0. 421-1/ if-ia_6,-Cc 4 g,06-) /4tie_. - SYS7-0-4 <br /> NOTE: If permit request is for any new construction,an addition,deck/fencing,or any alteration involving a structural <br /> modification,PLEASE SUBMIT(2)COPIES OF DETAILED PLANSalong with this completed application form. <br /> SAC Has a SAC determination been completed? [ ] Yes [ ] No [ N/A(Existing Residential Only) <br /> Determination If"No", refer to Service Availability Charge handout for more information.Copy of SAC determination letter must be <br /> (MCES) submitted prior to Building Permit issuance. <br /> Certification/Acknowledgement — A Certificate of Occupancy must be requested and issued prior to use or occupancy of work permitted. Work must be <br /> inspected before it is covered,24 hours notice is required. This permit shall be void if the work authorized is not commenced within 180 days of the date of issuance <br /> or if work is suspended for a period of 180 days. Term of permit is 12 months from date of issue. This permit may be revoked at any time for due cause or violation <br /> of any Federal, State or local law. Applicant agrees that if a permit is granted, all work and materials used shall comply with the City Code of Long Lake. <br /> X Applicant Signature Z.--Zu ,7Applicant Is: [ ]Owner [X]Contractor Date 9-2(-/7 <br /> Permit Fee Calculation <br /> Standard Permit Fees SAC&Sewer/ Water Charges (IF APPLICABLE) <br /> Permit Fee $ MCES SAC Charge- Units / SAC Credits-_Units <br /> Plan Check Fee $ Net SACs- Units @ $ = $ <br /> State Surcharge $ Sewer New Main Line Service Tap $ <br /> Penalty $ Water New Main Line Service Tap $ <br /> Other(DESCRIBE BELOW) $ Sewer Access Charge $ i J V O • n <br /> Water Access Charge $ <br /> TOTAL DUE $ TOTAL DUE $ ( I 6 0-79 -OV <br /> Code Analysis <br /> Occupancy Type of Construction Occupancy Load <br /> Use of Building Building Area: Existing SQ FT New SQ FT <br />