P - 41899Engineering WATER AND SEWER Permit No.:
763-572-3552 PERMIT APPLICATION Rece' `�
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763-571-1287 fax CITY OF FRIDLEY Date�ec'�: ��r���"
EFFECTIVE 01/O1/201 I
APPLICATION DATE: �! S� � YOUR E-MAIL/FAX: G�V i G� s1,�,s+G! w�+�l'+� ar..G% ,f�+.� , w�"� ,
TH13 APPLICANT IS: � OWNER 75�CONTRACTOR
.fOB ADDRESS: � /(t �S Z'~� .5�� • ^� �
NEW CONSTRUCTION PERM1Ti1 (IF APPLICABLE):
PROPERTY NAME: L'f`sb�•M�' �-,- ,t.I�,��++►M"^(.c�
OWNER/ ADDRESS: C1TY STATE ZIP
TENANT
PHONE:
CONTRACTOR NAME: ��.�'! '-V q HI� +�d
SUBMITA COPYOF �DRESS: 3i1 14� �a � . �+%���. �• +NCCITY �'N�� o �� +
YDUR STATE '""'''�^� STATE �LIP �"''r /d'
LIC$NSE W/TH PHONE �� L.-�dI�1�?'� CELL PHONE: �� 2•?�i- L8 6 t
APPLlCATION
STATE LIC �l STATE BOND: EXP DATE:
1. Narrative/written description: `�`_
��^ �r�iF ` rv u..J �•�1 a� �•VZ •�...�,✓ �!r"�✓� � "� i�o�+k � C� I° �AR'Id`-+ � ""C,-�
2. Please attach sketch showing curb tine, utitity line, building, etc. with distances on back page. rY�
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3. Stip�lations: "" �
' �,o � �.�.b-�. b� � ' (�,,� ,
3, 1���.�� � �'+a 6�' ��, J '
� , P ��.�--�r� �'
-� . 7�
, ^� p�g� T TYPE �/ 7� 3 2� SrOY $
�p . (�� 1,n `� z /1A7��
]C�.. _ t�-�� - 7 � ''� 'S�2 3 S� /
I�EWER COO�NECTTON PERMIT I. SEWER DISCONNECT PERMIT $50 � 76 3 572 3 SS6
I�IVATER CONNECTION PERMIT I WATER DISCONNECT PERMIT $50 �c.
� I WATER LINE REPAIR $40
I SEWER LINE REPAIR $40
I ADD STATE SURCHARGE $5.40 for each permit �-r
I SAC CHARGE @ $2230 =
TOTAL $ //O ° `�
OTHER CHARGES (IF APPLtCABLE) PAY TO UTILiTY BILLING
NEW WATER METER COST— SEE UTILITY BILLING
SPECIAL ASSESSMENTS — SEE FINANCE
WATER TAP — SEE ENGINEERING
NOTE: WATER METER REPAIR, INSP OR SHUT-OFF / EVENINGS, WEEKENDS & HOL[DAYS $125/HOUR-BILLED
TH1S IS AN APP[.ICATfON 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. 1 understand this is not a permit but
only an application for a permit and work i ot to start without a permit.
SIGNATURE OF APPLICANT � PRlN7' NAME: ��- �^�'v j-�► DATE: �<<
APPROVED BY: DATE: � �
COPY N �: [ UTILITY BILLING (only if new meter) t_i PUBLIC WORKS � � ENGINEERING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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