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P - 48349Engineering WATER AND SEWER Permit No.: �;� ��i 5 763-572-3552 PERMIT APPLICATION Received By: ��' �� 763-571-1287fax CITYOFFRIDLEY Date����: � �'g � ` EFFECTIVE O1/O1l2011 APPLICATIONDATE: �=� Z— YOURE-MAIL/FAX:I�tf.C(�2�STp 6jPk�l,'zNt`/TTy�ti`�"�iST-NL, t THIS APPLICANT IS: ❑ OWNER �'C6NTRACTOR JOB ADDRESS: �-j� � � � �e�— NEW CONSTRUCTION PERMIT# (IF APPLICABLE): PROPERTY NAME: ��"�i� � ' ,�"� � OWNER/ ADDRESS: Li���;�� ,1 �� / CITY STATE ZIP TENANT PHONE: CONTRACTOR NAME: `'y���~�-'�v� ���,��—�_��S SUBMITACOPYOF ADDRESS: '?i `�-� �%a? �� CITY YOUR ST,9TE � / � S7- 7�41..��- STATE�''�WLIP� (�-( LICENSEWITH PHONE���—(o�-(.�Z CELLPHONE: cp(Z��C��'-{'�-�� APPLICATION STATE LIC # STATE BOND: ��-L� EXP DATEc Z�j {�� 1. Narrative/written description: � �lJ 2�� �—��,L�'-�C? O �' S���n / .A�i�� l-- � ��� L�ruG2__ �2owi '���r �-.� � ot..�D� (n/�pr�r'�/ 2. PFease attach sketch showing curb line, utility line, building, etc. with distances on back page. 3. Stipulations: �, �2L-'C�� p�,;,...E,r�w�ct,� �}-� �. �!�l�L'L.rZ',�� c?v � �-�.c�.��'Y� �-i-c� � � �: �..� '� c � ,- . 6-�,�_v�e_ — C'✓✓�i�5.,-v:Jb�C.r; � �C �( � !a ` , �- ��. i..� � �.cc�v�a.�-�•�0 -- �� � � /�Q�(�iti2t�.� � 76���7Z-35>'2� ��� -3>5"G; �S�Z-3>4.� :y� Z3�°��' ) � r �/ F � ;� y`� ;l�AN �`� PERMIT TYPE (� L- i.v� 2 c AN:.,;, r F c 7t�%� �Z /�v'lo C.'' � TY 5 "„uF.cZ �'J'I�/.4.' ❑ SEWER C�SNNECTION PERMIT ❑ SEWER DISCONNECT PERMIT $50 ❑ WATER CONNECTION PERMIT ❑ S ER DISCONNECT PERMIT $50 ❑ ATER LINE REPAIR $40 SEWER LINE REPAIR $40 L/�') r ❑ ADD STATE SURCHARGE $5.00 for each permit —� �� ❑ SAC CHARGE @ $�3fl = �3(05 � 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 MET'ER REPAIR, INSP OR SHLTT-OFF / EVENINGS, wEExENDS & xOL1DAYS $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 conformance with the ordinances and codes of the City of Fridley. I understand this is not a permit but only an application for a permit and work is to �wit permit. � A ,�/j� - / SIGNATURE OF APPLICANT �'' � � � PRINT NAME: ��/+1L �� L�Q��J� DATE: { ' � _ APPROVED BY: DATE: t � � � COPY GIV Z' ❑ TILITY BILLING (only if new meter) ❑ PUBLIC WORKS ❑ ENGINEERING City of Fridley Engineering Department 6431 University Avenue NE, Fridley, MN 55432 763-572-3552 FAX: 763-571-1287 .� � c. M � o .,. . � 'Q Cr • l _ . O � �. _.., Benson, Jeannie From: Hiatt, Wendy Sent: Monday, January 30, 2012 8:51 AM To: Benson, Jeannie Subject: FW: Ticket 120300109 Sent by KORTERRA WEB -----Original Message----- From: do not reply(�korterraweb.com [mailto:do nnt reply(�korterraweb.com] Sent: Monday, 7anuary 30, 2012 8:35 AM To: gsrequest Subject: Ticket 120300109 Sent by KORTERRA WEB KORTERRA JOB CITY-LOCAC-1 120300T09 Seq: 1 01/30/201Z 08:35:24 Gopher State One CaII Locate Request ---------------------------------------------------------------------------- Ticket Number: 120309109 Old Ticket: By: TYLER H Source: VOICE Type: EMERGENCY Date: 1/30/2012 8:32:11 AM Send To: CFRD�Y81 Sequence: 1 Company Information ---------------------------------------------------------------------------- PIPELINE INDUSTRIES INC Type: CONTRACTOR 2274 CAPP RD ST. PAUL, MN 55114 Caller: WES CHRIST Caller Phone: (651) 645-0622 Contact: WES CHRIST Contact Phone: (612) 490-4708 Company Phone: (651) 645-0622 Company Fax: (651) 645-0673 Company Email: WES.CHRIST(�PIPELINEINDUSTRIESINC.COM Work Information ---------------------------------------------------------------------------- State: MN Work Date: 01/30/2012 9:00:00 AM County: ANOKA Done For: HOME OWNER Place: FRIDLEY Street: 830 OVERTON DR Intersection: ABLE ST Type of Work: SEWER SERVICE Explosives: No Tunnel/Bore: No Right of Way: Yes Duration: 1 DAY Remarks ---------------------------------------------------------------------------- CREW WILL BE ON SITE 1/30/2012 9:00:00 AM EMERGENCY REPAIR OF SEWER SERVICE MARK FROM FRONT OF HOUSE TO FAR CURB FOR WIDTH OF LOT. Members ---------------------------------------------------------------------------- Code Name Phone Number 1