P - 48389En�i��ieering
763-572-3552
763-571-1287 fax
APPLICATION DATE T_�/ ( /
THIS APPL[CANT IS: ❑ OWNER ON'
JOB ADDRESS: D
` NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME: �
OWNER/ ADDRESS: �
TENANT pHONE: i��Z
CONTRACTOR NA
SUBMIT A COPY OF
YOUR STATE AD
LICENSE WITH PH�
APPLICATION
#
1. N
WATER AND SEWER
PERMIT APPLICATION
CITY OF FRIDLEY
EFFECTI V E O l 101 /2011
_ YOUR E-MAIL/FAX:
�CTOR
���. �� ��
�zl�, � e.�'
CITY
,�,-- � —
;� Q� j � CELL PHONE: �
STATE BOND:
� r �
Permit No.:�
Received By:
Dar�a'a:� �
,�
STATE ZIP
2 �_zi�
�
EXP DATE:
�l` LC. GUl%�YcY
2. Please attach sketch show�ng curb line, ut►lity line, building, etc. with distances on back page.
t y
1 -g` r '.---i�-� .
� .. . �� �. ;
. ° j "�,�.
3. Stipulations: � • V✓L C 'l t�' �� ���; : �e �i � �F"`�� �� ��-- �-���
; � �, �ti y�-� �
PERMIT TYPE
❑ SEWER CONNECTION PERMIT i� SEWER DISCONNECT PERMIT $50
!_l WATER CONNECTTON PERMIT ��'. SEWER DISCONNECT PERMIT $50
� WATER LINE REPAIR $40
� SEWER LINE REPAIR $40
�� ADD TATE SURCHARGE $5.00 for each permit
❑ SAC CHARGE @ $2230 =
�� �
TOTAL $ -��
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING
NEW WATER METER COST - SEE UTILITY BILLING
SPECIAL ASSESSNfENTS - SEE FINANCE
WATER TAP - SEE ENGtNEERING
NOTE: WATER METER REPAIR, INSP OR SHUT-OFF / EVENINGS, wEExENDS & HoLiDa,YS $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a water or sewer (new connection or repair) permit and I acknowledge that the information above is complete and
accurate; that the work will be in nf rmance with the ordinances and codes of the City of Fridley. I understand this is not a permit but
only an application for a per ' ork ' n t st without a permit.
SIGNATURE OF APPLICA PRINT NA 1. ✓ DATE:
APPROVEDBY: / .-� .✓'"! DATE: ^
�, �
-..
C�PY �iTV T0: '7 TILITY BILLIN {Q�ly if new meter) ❑ PUBLIC WORKS ���.-� E IN
a'� `y of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
1
..
, ' MR ROOTER PLUMBING
5155 EAST RIVER ROAD, SUITE #412
FRIDLEY, MN 55421
TEL 763 551 0555 FAX 763 551 2555
Account # / AP Inv #
Name CHRIS COULTER
Address 970 HACKMANN CIR NE
City/State/Zip FRIDLEY, MN 55432
Main Phone/2nd (612) 805-3936
Map/Directions
Z-Unknown
Make Product
�
�
�
�
�
�
�
�
�..-
Tck # 39440 Received 6/8/2011 321:14 PM
Dispatcher ROYSTER
Promise Date/Time 6/9/2011 9:OOAM
Technician HANSON, KEVIN
Our PO#
Dispatch Code SEW REPAIR
3rd party PO#
3rd party Auth#
MFG# Serial #
�
R
�� A
� �,��
On.�D
��
��
�� ,
�� ,�
fl� �rf
�
�../
� �u���
��w,��k
ServiceFee
$o.00