HomeMy WebLinkAbout1982-12-02 Permit, Sewer & Water Connect #6892GENERAL PERMIT
CITY PERMIT NO. 6892 1
CITY OF OR( NO Date 1f�- -��
P.O.BOX 66
CRYSTAL BAY, MINNESOTA 55323
(612) 473-7357j7 1,,
Ownerki/ Address O ' � Sk
Contractor / 3r Address 656 (-�l//S — 96,64d—
City License No
REMARKS AND SPECIAL CONDITIONS
PERMIT TYPE AND FEE: NEW ❑ ADDITION
Inside Plumbing ( # fixtures ) Fee $
Water Meter (Size )
Meter #
Remote #
Fee $
Municipal Water Connection Fee $c
❑ Copper 0
Municipal Sewer Connection Fee $ _6
❑ PVC ❑ Cast n
MWCC SAC Charge
ACKNOWLEDGEMENT
Fee $ Pfi tU
The undersigned hereby acknowledges receipt of this limited
permit, including acceptance of all special information,
terms, conditions or requirements written above. The
undersigned understands and agrees under penalty of law
that this permit is strictly limited in scope to the work,
activity or improvement specified; that this permit does
not grant any authority to do work or activities requiring
separate permit approvals; and that this permit does not
grant authority to violate any provision of any City
ordinance or State law, rule or regulation. All work &hall be
done in strict compliance with all City ordinances, building
codes and/or health department regulations, and shall be
subject to inspection, approval or rejection by the City.
Whenever so ordered, the undersigned agrees to correct
any work found to be in vioiation of the conditions of
this _ rmit.
re of Applicant
State License No.
❑ REPAIR
On Site Septic System
Water Well
Mechanical Equipment
Moving/Lifting Buildings
Land Alteration (Excavation,
Grading, Filling, etc.)
Other:
After -the -fact Investigation
TOTAL
Fee
$
Fee
$
Fee
$
Fee
$
Fee
$
Fee
$
Fee
$
State Surcharge: Fee $
Total Amount Paid to City Fee $--A. 00
This permit is not valid until the proper fee is paid and
it is approved by an authorized City Official.
Sig t e of City Official
11-4
®�s
Code: White —Pile Copy Canary —Inspector's Copy Pink -Finance Copy Gold Applicant's Receipt