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P - 75070CITY OF FRIDLEY WATER AND SEWER CONNECTION PERMIT APPLICATION ! 1 Name:� � �-� ; : - '`°,.�!• -�� ,~/ i /`'` ;:;, Date: ��' v�c� 19 �"��. (Home Owner or Plumber) / � Jt Job Address:_ �tc��c ' � `� �/ �^( . LEGAL DESCRIPTION PERMIT: OR � �, SEYVER: '�' � � ..kJ FEE: ��- ' WATER: �'-. FEE: �� • METE R: DEP061T: O-DAPTER: STATE 4 ; �} STATE ?- SURCHARGE: "'' SURCHARGE: �� -} "'" 7 ! � j�-" �`,� TOTAI: ` '� '' -" TOTAL: f `�" "�-' TOTAL: = �y� �,� GRAND TOTAL: S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: NEW STRUCTURE: BUILDING PERMIT No.: J 9� SEWER/�IVATER PERMIT NQ.: 93 � ��. SPECIAL ASSESSMENTS - r� � -' � �, t _ - Signed� � 1'�'° �a ' '�T ,'~,/it ',�' ;..C�''rr; � � �`_ * ,�-r— L!' ! ��.-� By; + r 1.,�.' , %�� e'