Permits - Permit# 424 - 2418 Black Lake Road - 1/1/1982Account No.
APPLICATION FOR
PERMIT
Permit No.
For Connection To:
PERMIT FEES
Village of
Water
Water
Spring Park,
Sewer
Sewer
Minnesota
Meter Deposit
Tota I
Property Owner
Contractor
Q
Name L D
Address '� `I� •� ��� /�� /� L� kG ��
Name
Address
Telephone 2 _S 2
Telephone,
Permit No.
Expires:
To Be filled out for Both Sewer or Water
Legal Description of Property Plot H /06/ Lot
Parcel Block Add.
Has Assessment been levied? Yes No
No. of Building or unit to be served. Water
Sewer
Type of Building: Res. Comm'I. Indus.
Other
Are Water and Sewer to be installed in same trench? Yes
No
Is there Basement Under Bldg? Yes No
Full
Partial
Water
Use of Water. General
Approx. Mo. per year to be used
Size of Service Required:
Point of Entry to Bldg.
Meter Location
Special
The Undersigned hereby agrees:
To notify the Inspector when work is ready for
inspection, and not cover any work until such
inspection is made and the work approved.
Contractor
APPROVED BY
Remarks:
Sewer
Are all buildings properly vented
Service Pipe: V. Clay Cast Iron
Size Length
Point of Entry to Bldg.
Kind of Joint Used
Is Pretreatment Required? Yes
AFFIDAVIT
No
By signing this application, I do hereby declare that
all Statements herein contained, are true and correct.
That all work for which this application is made will
be performed in accordance with applicable Ordinance
of the Village of Spring Park, the State of Minnesota,
and the rulings of the Public Utilities Department.
If at the time this application is made, the Special
Assessments have not been levied, I do further con-
sent to the spreading of the pro-rata assessment
against the described property.
Date
Owner
FORM SW 1
CITY OF SPRING PARK
P.O. Box 452
4349 Warren Avenue
Spring Park, MN 55384
BUILDING PERMIT APPLICATION
OWNER i cc`,1 S j L i
PERMIT NO.
7 ✓ud"- U /
i95WO"Affl
ADDRESS .,-:�'Z /,S CLia i /� s ,( K e �7i�lo u .may tot a ss 3 6 yTELEP�iONE -192 - 3 S .s
BLDR--CONY __ a -TELEPHONE
Location of Proposed Improvement
D -
STREET ADDRESS EST. COST
_,1
PLAT ,? Z, S. '12 6 PARCEL 7�a `f a ZONING � .5 i '-y'
COMPLETION DATE ��c , i /9 z PIN NO. / 9
Application Requirements '6r0 65/0 o
Survey. Energy Comp. . . ._ Heating Layout. . . . .
Plat Plan. ... -Elevations . . . . . Sewer/Water location.
Structural Plan... Watershed County Driveway permit. .
Other.
Types of Construction
,iew Construction
Single family
Sq.
Multi. family
Sq.
..Commercial
Sq.
_Industrial
Sq.
Garage. -size
---size
Sq.
beck ____
Sq.
_Patio -size
Sq.
Fence --size
Ln,
emodelin
ft.
F'C�
4'S(�i7 _Addition
Sq.
ft._,________
ft.
_Interior
Sq.
ft.
ft •
_Sub lievei
Sq.
ft.'
ft.
ft.22�
Roofing
p? _Siding
Sq.
Sq.
ft.-
ft._
ft.
__Utility Bldg.
Sq.
ft.-
ft
c
ft.
PERMIT FEE _ a 3�,q0 PERMIT APPROVAL
SURCHARGE;
PLAN CHECK FEE a .3 PLANNING COMMISSION
$.A.C. .,_s. �. � m
AVAIL. CHG. COUNCIL
6THER OTHER PERMITS REQUIRED
TOTAL_ �y�so ) .Sewer/Water Connection
Plumbing _Excavation
Demolition n7
In case permit is granted, I hereby agree to do the proposed work in accordance
with description above set forth and according to the provisions of all the
ordinances of the City of Spring Park and of all statutes of the State of
Minnesota in such cases made and provi4ed-.)
DATE ZL9- /y -APPLICANT
5U