Permits - Permit# 3-27-17 - 2494 Black Lake Road - 1/1/2017, -
paQa
On Lake JKinnetonka
4349 Warren Ave
Spring Park, MN 55384
952-471-9051
FOR CITY USE ONLY
Date Received: Permit #
❑ In -House SAC Determination Form Completed
Approved By (If Required):
Remarks:
CITY OF SPRING PARK - SEWER & WATER / GENERAL PERMIT
(* Note: Some permits may require approval by the Building Official and/or Public Works Department')
(ALL PERMITS - May be subject to further review and may not be issued when the application is received)
GENERAL INFORMATION
1. You may apply for utility permits by mail or in person at the City offices.
2. Mailed in applications are subject to the postage and handling fee shown below. Permit cards will be sent by return mail
within 2 business days.
3. Permits are not valid until you receive a permit card.
4. Work must not begin unless the permit card is available on the job site.
5. Utility connection permits may be issued to licensed contractors only.
6. Contact the Public Works Department (952471-9051) for utility stub as -built locations.
DO NOT EXCAVATE IN ANY STREET AND DO NOT TAP ANY MAIN without express approval of the Public
Works Department. Issuance of a permit does not grant this approval.
7. All work must be done in accordance with State Code requirements.
8. All work must be inspected before it is covered. Call (952) 471-9051, 24+hour notice required.
TYPE OF PERMIT (Check All That ADnly)
Residential (May Require Approval) ❑ Commercial (Approval Required) LJ Industrial (Approval Required)
❑ New Connection ❑ Additional Connection [(Re -Connection ❑ Repairs [Disconnect
❑ Water Availability Connection for Future Hook -Up to Water
Job Site / Owner Information:
Site Address: Z
L Rz_,� ( _ /}-►�
Owner: I., g s
Mailing Address:
1r 82� 1 , M�� � �,
N'AJ
City: T i' t v r__ �,, A- a%f- Zip:
Home Phone: 6 1 Z' 211S - _3 I `" Z Alternate Phone:
Contractor Information:
Contractor: > , , &, ; w oa9 L_ I- G Contact Person:
Address: ) S3 L E State License #:
City: Zip: S'M Expiration Date:
Phone: . C '-2- - q 61' 4 aco Alternate Phone:
s t3 -4 =
/J AT -re 1n , n- - �-
136"4- i s
3 31 16
C i 1- zsl -970
macintosh hd:users.jasonphillips:downloads:spring park sewer & water permit.docx
Poor Quality Document
Disclaimer
The original or copy of a document or page of a document
presented at the time of digital scanning contained within this
digital file may be of substandard quality for viewing, printing or
faxing needs.
DETERMINING PERMIT FEES
❑ SAC Charge (2016 Rate = $2,485.00) $
(SAC Charge must accompany all sewer permit applications unless prepaid)
(Spring Park City Staff can determine if applicable)
(If not prepaid, a sewer connection permit will not be issued)
❑ Sewer Connection / Disconnect / Repair ($50.00/Per Stub) $
Pipe size inches; material Schd 40 air tested;
❑ Water Connection / Disconnect / Repair ($50.00/Per Stub) $
Pipe size inches; material air tested; copper
❑ Water Availability For Future Hook -Up to Water ($50.00) $
Water Availability Explanation:
Contractor installed line to inside of house for future hook-up.
This line will be inspected by the Public Works Department.
Required Before Water Connection Permit is Issued:
1. Issue Water Meter & Horn Permit
2. Any Additional Connection Fees Paid (If Applicable)
Issue Water Connection Permit:
1. Collect Permit Fee & Issue Water Connection Permit
1. SUBTOTAL of Permit Requested:
2. STATE SURCHARGE
1.00
3. POSTAGE & HANDLING (Only on Mail -In Applications) $_ 2.00
4. TOTAL PERMIT FEE (Add Lines 1-3 Above) $
ADDITIONAL INFORMATION — WATER METERS
■ WATER METERS must be picked up and paid for at Spring Park City Hall, these are on a separate permit.
■ WATER METERS must be set and sealed by Spring Park Water Department (952) 471-9051, upon completion of meter
installation.
The undersigned hereby applies to the City of Spring Park for issuance of a Utility Permit, agrees to do all work in strict
accordance with the ordinances of the City and the regulations of the State of Minnesota, and certifies that all statements
made on this application are, true and correct.
M—'1
Applicant: Date: r
Revised: 4/2 20
SEWER & WATER PERMIT
2
macintosh hd:users:jasonphillips: downloads: spring park sewer & water permit.docx