HomeMy WebLinkAboutLA203663SEWER AND WATER PERMIT APPLICATION
Office Use Only
___________________
Permit Number
___________________
Received By
___________________
Date Received
DATE YOUR E-MAIL ADDRESS
SITE ADDRESS
TENANT SUITE NO.
THE APPLICANT IS: RESIDENT OWNER CONTRACTOR
RESIDENT OWNER
NAME________________________________________________________________________
ADDRESS_____________________________________________________________________
CITY _____________________________ STATE_____________ ZIP _____________________
DAYTIME PHONE # WHERE YOU CAN BE REACHED ______________________________
CONTRACTOR
Company Name must be
as listed on State Bond
COMPANY NAME_______________________________________LICENSE #______________
BOND #:______________________________________ EXPIRATION DATE_______________
ADDRESS_____________________________________________________________________
CITY _____________________________ STATE_____________ ZIP _____________________
CONTACT NAME________________________________FAX #__________________________
DAYTIME PHONE # WHERE YOU CAN BE REACHED ______________________________
PERMIT TYPE
FOR: Residential Commercial Industrial
Is Street Excavation necessary? YES NO
If so, has Escrow or Bond been paid & Street Excavation Permit applied for? YES NO
(Call Engineering Department, 952-985-4500)
COMMERCIAL FEES:
JOB COST: $ Example: $12,000 Job Cost
1% of cost plus surcharge + $12,000.00 x 1% = +120.00
(Surcharge = Contract Cost x .0005) + $12,000 x.0005 = + 6.00
TOTAL = = 126.00
Minimum of +State Surcharge
I hereby apply for a sewer/water 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 Lakeville and with the Minnesota Codes; that I understand this is not a permit but only
an application for a permit and work is not to start without a permit; that the work will be in accordance with the approved plan in the case of all
work which requires review and approval of plans.
NAME OF APPLICANT (Please Print): Date:
SIGNATURE OF APPLICANT: _______________________________
$40.00 $1.00
TYPE FEE
SEWER/WATER CONVERSION
SEWER CONVERSION
WATER CONVERSION
COMMERCIAL
(INCLUDES WATER/FIRE LINE)
STREET DRAINTILE (TYING INTO CITY LINE)
MISC (INCLUDES PRIVATE SEWER
REPAIR/NOT SEPTIC SYSTEM)
$90.00 + State Surcharge
$90.00 + State Surcharge
$90.00 + State Surcharge
Per Commercial Fee Formula Below
+ State Surcharge (MINIMUM)
+ State Surcharge (MINIMUM)
+ State Surcharge (MINIMUM)
(INSTALL MANHOLES, ETC.)
$40.00
$40.00
$40.00
Submit to: permits@lakevillemn.gov
CITY OF LAKEVILLE
BUILDING INSPECTIONS DEPARTMENT
20195 HOLYOKE AVENUE
LAKEVILLE, MN 55044
952-985-4440www.lakevillemn.gov
5.00105.00
Molly Kroker 6/30/2022
SEWER AND WATER PERMIT APPLICATION PAGE 2
OFFICE USE
WORK TYPE INSPECTIONS
NEW BACTERIA TEST
ADDITION CONDUCTIVITY TEST
REPAIR FINAL
DEMOLISH HYDROSTATIC TEST
REPLACE HYDRANT FLUSH
ALTER/REMODEL SEWER LINE
STREET DRAINTILE
STORM SEWER
WATER LINE
OTHER
PERMIT FEE:
PERMIT FEE $
SURCHARGE $
WATER UNIT $
SEWER UNIT $
METRO SAC $
OTHER $
TOTAL $
APPROVED BY: DATE: