HomeMy WebLinkAboutLA184234 PERMIT
City of Lakeville Permit Type: Sewer& Water
20195 xolyoke Ave Permit Number: LA184234
Lakeville,MN 55044
(952)985-4440 * L R 1 8 4 Z 3 4 �K
www.ci.lakeville.mn.us Date Issued• 09/23/2020
Site Address: 8144 183rd St W
Lot: Block: Addition:
PID:
Use: Pinnacle Ammenity Building * *
Description:
Sub Type: Commercial
Work Type: New
Description: New Sewer and Water connection
Meter Size Meter Tvne Manufacturer Serial Number Remote Number Line Size
Comments:
Fee Summary: Descri�tion Amount Revenue Code
Valuation: 9,771.00 Surcharge-Based on Valuation $4.89 1000-2127
SW-Commercial $97.71 1000-4153
Total: $102.60
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Contractor: - Appli�ant - Owner:
M M Miller Brothers Excavating
20170 75th Ave N
Hamel MN 55340
(763)420-9170
I HEREBY AGREE THAT THIS WORK WILL BE PERFORMED ACCORDING TO: (1)THE APPROVED PLANS&
SPECIFICATIONS;(2)THE APPLICABLE CITY ORDINANCES&CODES;AND(3)THE MN STATE BUILDING CODE.
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ApplicantlPermitee: Signature Issued By: Signature
SEWER AND WATER PERMIT APPLICATION �!'�'�c�:�
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CITY OF LAKEVILLE Pmnit Number
BUILDiNG tNSPECTIONS DEPAI2TMENT GA
20195 HOLYOKE AVENLiE Receivod 8y
LAKEVILLE,MN SSU44 9�2��2�
952-��35-444U
wri�v.lakevillemn.¢av Date Receivcd
DATE � Y�UR E-MAIL ADDRESS N�.�'� � Wi 1 - Q �y�
sc-rE AVD�ss �1 � i$ 3�� S'C K�.e��-
TENANT SUITE NO.
THE APPUCANT[S: ❑REStDENT OWNER (�CONTRACTOR
NAME D�-' �'"�q�i--��C�h1
RESIDENT OWNER ADDRESS Z+�Q � � t��?nbY� dC1�Q, ��'
CITY_(u j��v�1\� STATE M"� ZIP �'G r S 4�„
DRYTiME PHQNE#WHERE YQU CAN BE REACHED
COMPANY NAME M/�4����O S G?��O!✓IX�`LI SE# �Ll�C���b
B�ND#�: 10(p�Q(e L�n� EXPIRATION DATE, t ` � ' Z �
con�r�►rroR AnD�ss l0�'t 0 "l S�'' h�. t�.i
Company Name must be
���s��a�,s�«�,a crrv__�0�'Q�A�--= sTAr� M►`� zrn `���O ___
CONTACT NAM� Ld tl�l�Y t� �1�lJ�a��.�AX#
DAYTaviE PHONE#WHERE YOU CAN BE REACHED � �Z. ' LZ l ' Q �,�q
TYPE F�E
�,�]SEWE�2lWATER CONVERSION 590,00+Scate Surcharge
❑SEWER t'ONVERSIQN �90.00+State Surchuge
❑WATER COIVVERStON �9Q.00+State Surcharge
PERMIT TYAE
❑COMMERCIAL Per Commeroial Fee Formula Below
(TNCLUDGS WATER/F[RE LINE) 544.04+g�atc Surcharge(MINIMIJM)
❑STREET DRATNTTLE RTYINC[?VTo CffY 1.TNE) �0•�+State Surcharge(MINiMUM)
❑ MISC(INCLUUES PRIb'ATE SEWER �4p,�+g��te Sorcharge jMtN[MUM}
ftEPAIRiNOT SEP'TIC 5Y5?EM} �TNSTALL MANH�LES,ETC.)
POR: Q Residential �Cammercial ❑Induscrial
Is Street Exeavadon neeessary?Q5'��O
[f so,has Estrow or Bond becn paid 8k treet Excavation Permit appfied for?�YES ❑NC)
1Ca11 En�ineerin�Departtnent,952-985-45401
QETAILED DESCRIPj,jQL�1 OF WORK• �C_� Se�.A�L Y �i v1� C�GtkJ�/ C�ri►'L2 C/�--�(j,,.�
COMMERCiAL F'EE�• n
J���n��� � I,r�ft.�� � i^ Exampie:512,000 Job Cost
1°lo of cost plus surcharge . 140.00 x 1°lo = + 120.00
iSurcharge=Cantraet Cost x.tl005) ' ' - ���,(10(i x.000� _ + 6,00
TOTAL % /� � = 12b.00
Minimnm of 540.1)O+State Surcharge�1.f)U �! ��
i hcreby appty for a s�vverlw�eter pe�mit and I acknowlalge tbat the infornistion abo��e is comptete and accurate; that the work will b� in
canftmna�ce with thc t�rdinanccs and codcs afthc('ity af lakev�lle and u�th the Minntsota(°odsx,that I understend thiF ia ncrt a permii t�rt nniy
an application tor a perrnii and work is not t+o start without a petmit;thac tho work wiil be in accordence rovith the approved plan ira the case of all
work which rcquira review and epproval of plens
NAME OF APPLtCANT(Please Print): pate;
SIGNATURE OF'APPLICANT:
SEWER AND WATER PERMIT APPLICATION PAGE Z
OFF'ICE USE
WORK TYPE II�ISPECTIONS
� N�W � BACT�RIA T�ST
� ADDITION � CONDUCTIVITY TEST
� REPAtR � FtNAL
r� DEMOLISH � HYDROSTATIC TES'T
� REPLACE � HYDRANT FLUSH �
� ALTER/REMODEL �SEWER LINE
�T STREET DRAtNTILE
� STaRM SEWER
� WATER L1NE
� OTFiER
PERMIT F�E:
PERMIT FEE $ �� . �C�
SURCHARGE � 1, (� �
WATER UNIT $
SEWER UNJT S
METRO SAC $
dTHER �
TOTAL S 0.00
APPROVED BY: DATE:
�OMMENTS: