P - 44176Engineering WATER AND SEWER Permit No.:
763-5�2-3551 pERMIT APPLICATION Re�ei�ed B��_
763-571-1287 fax CIT� OF FRIDLEY Da��'��� � 3���
EFFECTIVE 6/9/09
APPLICTATION DATE: I�'r�( �� 1 YOUR E-MAIL ADDRESS:
THIS APPLICANT IS: ❑ OWNER � CONTRACTOR � ^
JOB ADDRESS: S7�(i j� � S T N� r"�� C� � L� /►r� 5��� ?J Z
NEW CONSTRUCTION PERMIT# (1F APPLICABLE):
PROPERTY NAME: ��I . I-��'►t�
TENT ADDRESS: J7g� O7 �L J^�" N� CITY t`Y/ (' �'ty STATE/')'/NZIP S3�i��
PHONE: ��D:3° �� 1 3-- r`1 �J
CONTRACTOR NAME: A�'�� C�(1 /tC� ( (}+'l i vt .� i�Gt,�'ri L-G �',
SUBMITA COPYOF �DRESS: ��(p�iA �.iG�l�1,t�G(S�� B� CITY �1t; if✓1 C.!_( STATE�ZIP S�%�
YOUR STATE
LICENSE WlTH PHONE _ _ % C^�,3-' �,�j � -�� �y � CELL PHONE: %3' �3 g' U� � �
APPLICATION STATE LIC # STATE BOND: 7 DO ii EXP DATE: �' 3 J� o��'���'J
1. Narrative/written description: � _� CV ,� b s t� l f^�- �0 V�-�.
�Ce.� lcf.c�. u�c�e.✓ s�P� `�`� l i�: �p
2. Please attach sketch showing curb line, utility line, building, etc..with distances. __
PERMIT TYPE
❑ SEWER CONNECTION PERMIT $50
❑ WATER CONNECTION PERMIT $50
� WATER LINE REPAIR $40 �� - �
❑ SEWER LINE REPAIR $40
❑ ADD STATE SURCHARGE $.50 � �
❑ SAC CHARGE @ $2000 =
�t'wti- �D- 5�
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING
NEW WATER METER COST — SEE UTILITY BILLING
SPECIAL ASSESSMENTS — SEE FINANCE
WA'TER TAP — SEE ENGINEERING
NOTE: WATER METER REPAIR, INSP OR SHUT-OFF / WEEKENDS & HOLIDAYS $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a water or sewer (new connection or repair) 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 Fridley. I understand this is not a permit but
only an application for a pe ' d wor is not to start without a permit.
SIGNATURE OF APPLIC PRINT NAME: o11vr� �jy� yy� �j�� r� DATE: /, ���U �
APPROVED BY: ' DATE: � C / O�_
COPY GIVEN :❑ TILI BILLING (only if new meter) Q PUBLIC WORKS ❑ ENGINEERING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3551
FAX: 763-571-1287
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