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CITY OF FRIDLEY
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WATER AND SEWER CONNECTION PERMIT
APPLICATION
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PERMIT: °
SEYVER: `f WATER: �'
FEE:��! FEE• /��
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METE R:
DEP0611':
O-DAPTER:
STATE � STATE �
SURCHARaE: SURCHARGE:
TOTAL:iC�li� �v TOTAL:Li � `°'.� TOTAL:
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GRAND TOTAL:
CHARGE ON EXISTING STRUCTURE:
EX6TING STRUCTURE: „„ NEW STRUCTURE: r
BUILDING PERMIT No.: S V SEWER TER PER NO.:_ 3
SPECIAL ASSESSMENTS: Si�ned: �
sY: b�