Permits - Permit# L11-18 - 2413 Black Lake Road - 1/1/2011.t V'Dec. 20, 2011 11:18AMt1ec'MNSPECT
y3«y'0I-XI No.4756 P. 1
CITY OF SPRING PARK
ELECTRICAL PERMIT
Peimit Number
PLEASE PRINT OR TYPE A I.L INFORMATION AND COMPLUIR ITEMS ON BOTH SIDES � �( /
Check appropriate boxes. Fill in appropriate blanks. "JIT "\ r
ouanuly DESCRIPTION OF WORK FEES subfr*Ml
you n►ust call the inspector 452.442-7520when %zork is neadv for insneetion
Describe Proposed Work: ��L- U�
Separate Permits are required for any building, meebanical, fire, or plumbing work. WK
"". ",Dec. 20. 2011 11:18AM---MNSPECT
V VL.'ZVV'V IVV No. 4756 P. 2
PLEASE PRINT OR TYPE ALL INFORMATION
COMPLETE 1TEMS ON BOTH SIDES
JobSite: Street Address: ?," j V1 RLA C-K u9 ;:.E
Citysigl %xC -90,PX Zip: S&3 County:. HF,1�0 E- P� tJ
Legal Description: Lot: Black: Subdivision Ni ame:
Property I.D. (PIN) No.
Applicant is: Contraetor:-�k— Or Owner:
Contraetur/Company Name: Z IE- C RK ,b
Address: ?0qZ4 1 !6 city: MOON i _
r
State: —o zip: Contractors License #:Ck� % C, 1E+-mail PAi t o m
Telephone: Office:( Mobil:(Liz-) - 3-Dc�Fax:aiZ) -1 t A r
Builder/Owner Name: j Z>-Ak) LE � --
Builder/Owner Telephone: Office/Home- ( 1 Z)- �o� Z• Mobile.(
E-mail: Fax: (� --
I HERERV APPLY FOR AN ELECMCAL PEaMIY, AND I ACXNOW LEDOf TRAT T11G INFORMATION ABOVE IS COMPLETE AND ACCURATE; i
UNDERSTAND WORK IS NOT TO START WITHOUT A PMMn'. I UNDMWAND AND HEREBY AOR'EE THAT THE WORK FOR WHICH THE
PERMIT IS ISSUED SHALL BE PTtRFORMEO ACCORDING TO THE FOLLOWING: (1) THE CONDITIONS OF THE PERMIT, (2) TM APPROVED
PLANS AND SPECIFICATIONS. IFNEEDED (WHE APPLICABLE CITY APPROVALS, ORDINANCES, AND CODES, AND (4) THE STATE
BUILDINGIELBCTRICAL CODE'. I UNDERSTAND THAT 71W PERMIT WILL EXPIRE, AND EI_COMENULL AND VOID IF WORK IS NOT
COMPLEM WTfMIN 13 MONTHS OF VALIDATED DATE AND, THAT I A.N RESPONSIBLE FOR ENSURING THAT ALL REQUIRED
INSPECTIONS ARE PJMU99;7'EQ IN CONF)RMANC&WITH THE STATE DUU.W NOGLECTRICAL CODS,
Date:
0 Check Attached — Check # Mdm chtd s pgcblc to i(MPECT, mail payment to P.O. Nox342'iWaoomit4 MN $5387
MAIL-. MNSPECT, P. O. Box 342 Waconia, MN 55387
FAX: 952-442-7521
UELM E;R: tv1NSPECT, 215 West First Street Waeonia, MN 55387
)K Visa/MasterCard m
Account mber C uKpindou Data Amount (a bo wlth4rewn
Credit CnrdOwwrBilling Addr=lA%L( IP I (,.9?4 C1. 1.,i- ROSLr`vbvP+\ V)per, SS b L-g5
Street Addms � City, 91stc Zip Code
Payment Authorizati tare (REQUIRED)
FOR OPrice u5E:
tYl� C—l" EL S Receipt Date Initials
Print Name on credit card (REQUAtED)