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P - 41836Engineering WATER AND SEWER Permit No.: � �2Y � 763-572-3552 PERMIT APPLICATION Received By� �'�''`� 0 763-571-1287 fax CITY OF FRIDLEY � cFFECTivE ovouzoi i ����e��.� . �. APPLICATION DATE � YOUR �-MAIUFAX. THIS APPLICANT IS: ❑ OW'NER �ONT CTO.R` IOB ADDRESS: �57 �� � ��� J�1 �., , NEW CONSTRUCTION PERMIT# (IF APPLICABLE): PROPERTY NAME: OWNER/ ADDRESS: CITY STATE ZIP TENANT PHONE: CONTRACTOR NAME: � Z SUBM/T A COPY OF �n /YV`� / YOUR STATE ADDRESS. CITY LICENSE Vf'ITH PHON�"]�Z S�' �— QC���� CELL PHONE: �p �E 3�t2�.ss� APPL/CA T/ON STATE LIC tl STATE BOND: EXP DATE: l. rrative/written descr' tion: � �,.., ' ,�,� � .� -- r 2. Please attach sl<etch showing curb line, utility line, building, etc. w th distances on back page. � 3. Stipulations: i- - ----- I PER1�71T TYPE I SEWER CONNECTION PERMIT I SEWF_.R DISCONNECT PERMIT $50 I WATER CONNECTION PERMI"I� '� WATEK llISCONNECT PERMIT $50 i WATER LINE REPAIR $40 i SEWER LINE REPAIR $40 � � I ADD STATE SURCHARGE $5.00 for each permit `� `� ' SAC CHARGE @ $2230 = c:%�� TOTAL $ � � OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING NEW WATER METER COST — SEE UTILITY BILLING SPECIAL ASSESSMENTS — SEE FINANCE WATER TAP — SEE ENGINEERING NOTE: WATER METER REPAIR, INSP OR SHUT-OFF / EVENINGS, wEEkENDS & HoLtDaYS $125/HOUR-BILLED I�HIS IS AN APPLICATION FOR A I�FRMI"��-NO"I� VALID UNTIL PROCLSSGD I hereby apply for a water or sewer (new connection or repair) permit and 1 acknowledge that the information above is complete and accurate; that the work will be ' c�formance with the ordinances and codes of the City of Fridley. 1 understand this is not a permit but only an application for a nn� d work ' nc,J�t sta without a permit. SIGNATURE OF APPU PRINT NAM� � DATE: % �' .- APPROVED BY': DATE: �� � � COPY GIVEN TO: � UTILITY BILLINC (only if new meter) I PUBLIC WORKS I ENGINEERING ; ,�' City of Fridle_y Engineering Department 6431 University Avenue NE, Fridley, MN 55�32 763-572-3552 FAX: 763-571-1287 MR ROOTER PLUMBING 5155 EAST RIVER ROAD, SUITE #412 FRIDLEY, MN 55421 TEL 763 551 0555 FAX 763 551 2555 Account #/ AP Inv # Tck # 40603 Name CITY OF FRIDLEY Address 4757 2ND ST City/State/Zip FRIDLEY, MN 55421 Main Phone/2nd (763) 572-3591 Mem. Exp. Date Map/Directions Z-Unknown Make Product Model � • A� �ri '��, - � f�d C� e��. o��--�- . � � � � � � � 2�a� �' �• � R@C@IV@d 9�6/2011 2:5826 PM DiSpatCher DENNIS Promise Date/Time 9m2o� � s:oo Ann Technician HANSON, KEVIN Our PO# Dispatch Code SEW REPAIR 3rd party PO# 3rd party Auth# Install Serial # i�¢�A•� �L. W�i..t, n �.+r � H't�� t�Q�i4-+.�+ �j X lo � 1�.creABefL ServiceFee $0.00 � e.c� e� 1 w�-�.