P - 48285Engineering WATER AND SEWER Permit No.: G
763-572-3552 PERMIT APPLICATION Received By: 'I�_
763-571-1287 fax CITY OF FRIDLEY ,�
EFFECTIVE 01/O1/2011 Date �e���
APPLICATION DATE: `�Z�f 9�/f YOUR E-MAIL/FAX:
THIS APPLICANT IS: O OWNER �ONTRACTOR
JOB ADDRESS: ��{ 7 .S ,�� +�rG �e-
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME: �''�GS�! o �I
OWNER/ ADDRESS: I�'.� S 3'� r7�-C �T�`- ��' STATE� ZIP
TENANT
PHONE: �I �,�.. �i'L a / d2d°
CONTRACTOR NAME: G�aw-� �K .-v� �l �.
SUBMIT A COPY OF
YOUR STATE ADDRESS: ;`3l,��/ Csi. +s�r"+�.t c�� N�C►Ty �^+y�� �•, S1'ATE�'''"ZIP -j ��%
LICENSE WITH PHONE _ CO /Z - 8tai �Z? ��+' CELL PHONE: Ci� 2' 3'Z�"" 2.�"6`; •
APPLICATION
STATE LIC # STATE BOND: EXP DATE:
1. Narrative/written description:
nr'� Av�.� G`►;c �c.v�� l�� LfavC� �a �'-�-� �'�+.l�.�.
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations: �•t 5 �D �f' Cc� rn a e� : J�n y� e�- �►0 r� �� S�� /a CoW� �, a h t
s��e+ v�n��su��s ��r exCava���v� ,�al 2 hws r�c�s
i�S�Pet,��h.
PERMIT TYPE
0 SEWER CONNECTION PERMIT ❑ SEWER DISCONNECT PERMIT $50
❑ WATER CONNECTION PERMIT 0 WATER DISCONNECT PERMIT $50
❑ WATER LINE REPAIR $40
0 SEWER LINE REPAIR $40
❑ ADD STATE SURCHARGE $5.00 for each permit
❑ SAC CHARGE @ $2234 =
TOTAL $ � �
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING
NEW WATER Iv1ETER COST — SEE UTILITY BILLING
SPECIAL ASSESSMENTS — SEE FINANCE
WATER TAP — SEE ENGINEERING
NOTE: WATER METER REPAIR, INSP OR SHUT-OFF / EVEI�TINGS, WEEKENDS & HOLIDAYS $125/HOUR-BILLED
THIS IS AN APPLICAT[ON 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
accura.te; 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 perm�t o�s not to start without a permit.
SIGNATURE OF APPLICANT �I /�� PRINT NAME: �"� '��f-�-- DA7'g; � t�� q° //%
�
APPROVED BY: " DATE: � Z' Q"' � I
COPY GIVE �: ❑ UTILITY BI LING (only if new meter) ❑ PUBL[C 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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