P - 48488�� '
�ngineering . WATER AND SEWER Pe�mit No.: -� p' :
7b3�5��-3552 PERMIT APPLICATION Received By: ��
76�=57 �-1287 fax CITY OF FRIDLEY ���� ;
� ' ' EFFECT[VE 01 /01 J2011
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APPLICATION DA'I'6: t IJ YOUR E-MAIL/FAX: " _
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TI3TS APPLICANT IS: O OWNER . CONTRACTOR ,,/
�os A��x�ss; �i.2� / - /e/2C2 ��f �, �
NEW CONSTRUGTIQN PERMIT# (IF APPLtCABLE): �°
PROPERTY NA1vtE: . �' ' ; �
OW1�iER/ ADDRE3S: CITY ` STATE . ZIP ' `�'
TENANT PHOrtE: `7 �i I � �Z�
�P�> �L� 7
CONTRACTOR NAt�tE: '� Ln
SUBMIT A COPYOF ADDRESS: "� .� �' TE 2�,;?�.�.��
YOUR STATE
LIC'�'NSE f�ITH PHONE����� DJr�� CELLPHONE: �j�0/�� �
APPLICATION
STATE LIC # STATE-BOND: EXP DATE: r
L Narrative/wri�tte�n de� ption: L� G� �/ `
12�� Jv L/� d
- � �
2. Please attach sketch showing curb line, utility line, bui�ding, etc. with distanees on back page.
3. ,Stipulations: � -
;� �
c \
` PERMIT TYPE � . � ;:
❑ SEWER CONNECTION PERMIT � SEWER DISCbNNECT PERMIT $50 ' '., -
❑ WATER CONNECTION PERMIT �:; SBWER DISGONNEC'T PERMIT $50 (' '
; !� WAT'ER LINE REPAIR , $40
J SEWER LINE REPAIR $40
. ❑ `ADD!STATE SURC�IARGE $SAO for esch permit �
� SAC CHARGE _ @ $2230 =
, , "1 � �`/
TOTAL $
OTHER CHARGES (IF APPLIGABLE) PAY TO UTILITY BILLING
NEVV WAT'ER METER COST - SEE UTILITY BILLING �, '. ;\.
5PECiAL ASSESSIv1ENTS - SEE FINANCE , -
� WATER TAP - SEE ENGINEERING , .
NOTE: WATER METER R�PAIR, INSP OR SHLTT-OFF /£VENINGS, WEEKENDS & OLIDAYS 5125/HOUR- LL�D ;
THIS IS AN APPLICATIOW FOR A PERMIT-NOT VALID UNi'[LPROCESSED
�
I hereby apply for ,a water or sewer (new connection or repair) permit and I acknowledge that the informatlon abovtt 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 d ork i not to art without a perrr►it. � "
SIGNATUREOFAPPLICANT pRINTNAME: lJGl11 fif//%(Kr , DATE; l G� lI �
APPROVED BY: � DATE; � O J l I
C�PY �il�+ � 0: ❑ UTILITY BiLLING (only ff new meter) 0 PUBLIC WORKS �_� �NGINEE#t,ING
t.ity ot 1�'rialey � ;
Engineering Department ;
6431 university Avenue NE, Fridley, MN 5�432 �
,
763-572-3552 �,,
FAX: 763-571-1.287 1
� � -
, .
, MR ROOTER PLUMBING
rl 5155 EAST RIVER ROAD, SUITE #412
, FRIDLEY, MN 55421
TEL 763 551 0555 FAX 763 551 2555
Account # 1 AP Inv #
Name LARRY CASE
Address 5251 PIERCE ST
CitylStatelZip FRIDLEY, MN 55421
Main Phone/2nd (763) 571-2922 (763) 571-2922
Map/Directions
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Make Product Model
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Tck # 37352 Received 1/3/2011 12 54:34 PM
Dispatcher KUNZA
Promise Date/Time 1/4/2011 10:OOAM
Technician HANSON, KEVIN
Our PO#
Dispatch Code S REPAIR
3rd party PO# ServiceFee
3rd party Auth# �o.00
MFG# Serial #
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