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SEWER AND WATER PERMIT Permit Fee. ~
AND REGEiPT T stotesurcltorge... . so
TpTAL FEE PAI . ~n _ nn
,K1e`rlil~ '~a nrv / Stile'~ilt Ro es, Inc .
Pem+ission is t?.rby proofed to
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Building on Lot No. 6 81ock ~ Subdivision , V" f t `t'
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PstYeel ~d22-2t1~F,~-tt6~?-~?_ Ptat
in the CITY OF t.AKEVILLE to be used as Permit to cdnnec t toc ctF'ty ~e~er anc'i wetter systems
~ This permit is issued on the express condition that the .yERECTION -ALTERATION ;REPAIRS
-INSTALLMENT .MOVING' DEMOLITION respecfsll to~the statements certified to inr the appiiWfion for
wch permit, and that all work shall' be done in;-accordance with the Ordinance of hAKEVILLE, Min~ots and the State
a~f Minnesota pertaining to fhe construction of buildings.
Street Addre;s 16134 Fxcel sior Court ;
Director, Lien aodrlnspection
pttgntionb perkculaYly calbd to the Wttingup of streets, making main sewer connections. drweways and
CUrba. tJbtainpermit for eUCh construction --from the CITY OF LAKEVILLE. Inspection Department Not
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Responsltile For Arty Damege8 to PubNc tJddties.
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The permk hOtder understands end sprees that granting this permit is not a warrarrty or representation by L i
the Gty thffi the project wa be safe or satisfactory. f , r
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The peimk holder understands and agrees that the City shall have the right to make periodic inspecton
during conetruction..kthe permk holder tloes not make arangement to the inspection the City may tum
off thewater undl such dupectkm tree. tieen made.
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CITY OF LAKEVILLE
,SEWER AND WATER PERMIT APPLICATION
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Job Site Address ~ ~ ~ - h
Legal : Lot !-~~.Se_ Block ~ Addition ~ p,.. f~T=~_~''_ 1~ ,
Owner or Builder i ,L, ~ / ,S/o-~ ~ ~ n
Excavating Contractor - ~ ~t
Address _ ~ h ~,sr~ ~ . City t~ ~Ot, ~cL~£JP Zip s ~ .
Private Sewer System ($29.50 + .50)
Private Sewer Repair ($14.50°•+ .50) $
Sewer & Water City Connections*(29.50 + .50). $ (3
Inside Plumbing-Conversion (15.50 + .50)• $
Sewer Connection Only ($14.50 + .50). $
Water Connection Only ($14..50 + .50). - $
Meter--($60.00) &--Pressure Reducing Val~ze. $
* Metro SAC Charge S/W Connection.-Units $
TOTAL CHARGES $
Is Street Excavation necessary? Yes
No
Signed
Make checks payable to: City of Lakeville
Send payment to: City of Lakeville Glenn A. .(Barney) Langord
Inspection Dept. Plumbing & Heating Inspect.
Box 957 .
Lakeville, MN 55044 Tel: (612) 469-4431.