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eir____PRIO,. CITY TEmpoRARy O B F UILD zoN ENE IN G G P c0 ERV I JAN eE ,.0 Date Reed
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.--"14.1°Z AND VERITY CONNECTION PERMIT
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IL Whitir rullr
3 ?tilik Ciirty 1 PERMIT NO. / / / / 3 4_
3 lb.v Adaiiitant I.
DPIkasetwearpribtadOknatiolleon)
ADDRESS 1 I
1 ' ZONING (ezeicenarae)
5460 fiireedDaccutsn Clink SF,, refer take, &IN 5,53'772
11
LEGAL DESCRIPTION (6,11,4.. age agnky)
LOT BLOCK ADDITION PID
OWNER
(Nanne)Gabriell Coffman (Phone) 952-210-6806
(Address)5460 Woodiamm Circle SE„ Prior lake„ MN 55372
BUILDER
(Com1+.1, i n? Name) (Phone)
(Contact Name) (Phone)
(Address)
TYPE OF WORK 0 New Comstrattion IliDark DEW& ffie-IltetuAim.P.; illifie-YolndC1 1 ntower Levet Fri 0 Fireptar_e
nAniflinoir DAllarrathimm OlIttitity Comumention
1 CODE DIRE. OHM_ CE Ms=
Type of Coosihnediaffir 1 11 HI IV V A B
Onaugromey Graffir A B E F Fl i M It S II PBOIELT COST/VALUE $
DionisieHrc 1 2 3 4 5 (caltiormgland)
n :,....,,, ofIrtlify Mint 11 &we Iferninkmal llontierrilmeniiala am die apyibicaties wan& ns tm *ye &est et my limicaikeeipe =me and cffuneutt hew certify der 4 annn tie canter or andrerated agent dr nine
a i r o o t - o r m u t w o r t i l per sly a n d O a t a n e n e n d r u l d l i k e n WM m a d a m l e a i l l e k e t i a i g d a r e a n d l e r i l i l a m s a n a l a i d g l p e r m e d i n n a c e m e d i a n o c m i d l a S i E b s e a t t g e i l l g r i m & 4 ma imam td imit like linking 1
1 adinitail cam 'revoke dins permit Ter Oast muse Pandlerniarie, 11 hereby ageere dealt idle any atilkia @IT a desepace may eiaten upon: due penile-tray ate parfaerna needed inspectimms. 1
A otif , 4.141i1,.' r Cops License Nut Dior
Permit Valiuratiion Park Support Fee 44 1 $
Permit Fee $ , SAC * $
{' lc ill Check Fee $ 1 Water Meter Size 5/8"; 1'; 1 $
i State Saircharge $ Pressure Reducer $
,
1 Penaky $ Sewer/Water Connection Fee * $
t' Iti ,,,,) Plini: Pernik Fee . $
Water Tower Fee * $
Mechamal Pernik Fee $ I 1 Milder's Deposit 1 $
Sewer ,'; Water Permit F'ete ' $ Other 1 $
. .
Gas vi, 'lc. t.,: Pernik Fee $ TOTAL DOE
i
IcC $ /g 75
ibis' ApyrratnuniBernmeslinw Beaffigg PezeoltWbes Approved Paid 7 1_ is' - iota (,1-#...27
Date
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24 hi nofiliv tow sti Wigwam* (Mt 447-4teNt. t* (952)4V-41245