HomeMy WebLinkAbout5265 Miller StreetFrom: no-reolv(alci.wheatridae.m. us
To: CommDev Pets
Subject: Online Form Submittal: Sewer or Water Line Repair Permit Application
Date: Tuesday, November 23, 20219:36:45 AM
Sewer or Water Line Repair Permit Application
This application is exclusively for SEWER OR WATER LINE REPAIR - IN YARD
Your Permit will be emailed to the email address provided below once it is
processed.
THIS APPLICATION DOES NOT CONSTITUTE A PERMIT. DO NOT BEGIN
WORK UNTIL PERMIT HAS BEEN ISSUED.
Right of Way permits must be applied for with the Public Works Department.
Is this application for
Yes
sewer line or water line
repair - in yard only?
PROPERTY INFORMATION
Is this Residential or
Residential
Commercial?
Property Address
5265 Miller St Wheat Ridge
Property Owner Name
Department of Human Affairs
Property Owner Phone
720-260-5122
Number (enter WITH
dashes, eg 303-123-
4567)
Property Owner Email
nia
Address
Attach City of Wheat
WRP 11-23-2021 Ddf
Ridge Electronic
Payment Form - "DO
NOT ATTACH A
PICTURE OF A
CREDIT CARD"
CONTRACTOR INFORMATION
Contractor Business
The Elite Pipe MD
Name
Contractor's License 120161
Number (This is a 5 or
has been issued and
posted on the property.
I certify that I have Yes
been authorized by the
legal owner of the
property to submit this
application and to
perform the work
described above.
I attest that everything Yes
stated in this
application is true and
correct and that
falsifying information in
this application is an
act of fraud and may
be punishable by fine,
imprisonment, or both.
Person Applying for David salvidrez
Permit
Email not displaying correctly? View it in your browser.
6 digit number for the
City of Wheat Ridge)
Contractor Phone
720-662-4381
Number (enter WITH
dashes, eg 303-123-
4567)
Contractor Email
david@elitepipemd.com
Address
Retype Contractor
david@elitepipemd.com
Email Address
DESCRIPTION OF WORK
Is this a sewer line or
sewer Line
water line repair?
Length of repair
18' long excavation, 3- 6' long repairs
Location of repair
In common area.
(backyard, frontyard,
etc)
Provide additional
Installing 3 sets of clean outs in different spots on service line
details including
installation of clean-
o uts.
Project Value (contract
5700
value or cost of ALL
materials and labor)
SIGNATURE OF UNDERSTANDING AND AGREEMENT
I assume full
Yes
responsibility for
compliance with
applicable City of
Wheat Ridge codes
and ordinances for
work under any permit
issued based on this
application.
I understand that work Yes
may not begin on this
property until a permit