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�°��' )
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�/ 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
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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
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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
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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
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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
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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
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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
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Code Name Phone Number
1