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GENERAL PERMIT CITY PERMIT NO. --'7064 <br />CITY OF OR0.T 0 -�-1/_,�3 <br />P.O.BOX act Darr <br />CRN S I AL. BAY, MINNESOTA 55323 <br />(61 _') 473-7357 <br />/ / <br />Ot+ner %�� � � ` <br />Address � �-n oz), _ <br />Contractor XQ/ &-z4wress 1,31& L-) _ <br />City License No. _---._.--- -- State Liccww No. --_-- _-- <br />Rl MARKS AND SPI-CIAL CONDITIONS <br />PERMIT TYPE AND FEE: 0,NEW ❑ ADDITION <br />ln,.ille Plumbing ( # fixtures ) <br />Water Meter (Size ) <br />Meter # <br />Remote # <br />Municipal Nater Connection <br />El Copper Q <br />Fee S <br />Fee S <br />Fee S <br />Municipal Scwcl- Connection Fee S <br />❑ PVC' ❑ Cast Q — --- - — <br />MWCC SAC Charge <br />ACKNOWLEDGEMENT <br />Fee S <br />Thr undersigned hereby d%knuwledg— receipt of this limited <br />permit. including acceptance of all special inform.tion. <br />terms, nonditions or requiremrims written above. 'rh, <br />undersigned understands and agrees under penalo of law <br />that this permit Is strictly limited in stupe to thc wurk. <br />activity or improvement specified; that this permit dues <br />not grant any authority to do work or activities requiring <br />separate permit approvals; and that this permit does not <br />Rant authority to violate any Provision of any t it% <br />ordinance or State law, rule or regulation. Aa work shall bo - <br />done In strict compliance with all Cidin <br />ty ordinances, building <br />codes and/or health department regulations, and shall bo- <br />subject <br />esubject to inspe.tion. approval or mlection by the Cit% <br />Whenever so ordered, the underaigned agrees to torr- t <br />any work lound to be its %iolatlon of the cunditlons of <br />this p,rrmt <br />S a re o oft: axil <br />1 <br />ILL, <br />❑ REPAIR <br />Oil Site Sepik systelll <br />Water well <br />Mechanical Equipment <br />Moving/Lifting Buildings <br />Land Alteration (Excavation, <br />Grading, Filling, etc.) <br />I-ce <br />S <br />Fee <br />S -c" <br />Fcc <br />S <br />Fee <br />S <br />Fee <br />S <br />Other: Fee S <br />After -the -fact Ime.tigatit>n Fee S <br />TOTAL <br />State Surcharge: Fee S • J �� l <br />Total Amount Paid to City Fee � <br />This pennit is not valid until the proper fee is paid and <br />it is approved by an authorized City Official. <br />Sign't e o1 t It\ OI ficial <br />�Q <br />it's Cupy Pink 1 inane Copy Gold Applicant's Receipt <br />