P - 48067Engineering WATER AND SEWER Permit No.:
763-572-3552 PERMIT APPLICATION Received By:
763-571-12g% faX CITY OF FRIDLEY Date R�I1 N( Y� A
EFFECT'IVE01/O1/2011 �'�,���_ 011
APPLICATION DATE: -J "' 31 ��0�� YOUR E-MAIL/FAX
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
JOB ADDRESS:
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY �pME:
OWNER/ ADDRESS:�1�J1 �%!/ ����0 �I�oCITY STATE IP
TENANT pHONE: ��T ,�7c� ^ � ��
CONTRACTOR NAME: �° 1�'' ��� l��rl�f1 sr.� S L° C�J �'
SUBMIT A COPY OF -T `T �� rn
YOURSTATE ADDRESS: �3%f�n ��� 11 /AJ��� CITY /'/ /� ST,ATFJ�AA>ZIP ,S�O�j
LICENSE WlTH PHONE �7/�=��.`�,'^ %i0 CELL PHONE: _�y�/`/� a' 2e2 (^ S�e�'�iJ '_
APPLICATION L�� STATE BOND: �. O 07 I EXP DATE:
STATE LIC #
L Narrative/written description:
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations: � � /� �l / /�` �z°�L°-/1 �'� %�%L L �✓� %�I� f, L/�I�i/
� . A 1. ��9:, �.l„�S�— � 2 . --t✓i_S►.,I�lJ�. �' t : ;,N. y' � . � ` ''t . .
3 . �� c�� �r�- � � Ji-� �r�-X) `[ . �-�.-QX vrio�Jst�c.� wl Z1�25 ,,y�l1,
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S � �..¢.h.`� �.Q �..1 � � MIT TYPE � �
_ � _ �%6� ° 23�S-8oy8 �-
76 3-� 38 � 80 58 r�
❑ SEWER CONNECTION PERMIT ❑ SEWER DISCONNECT PERMIT $50
❑ WATER CONNECTION PERMIT C; SEWER DISCONNECT PERMIT $50
❑ WATER LINE REPAIR $40
c�! SEWER LINE REPAIR $40 p
L ADD STATE SURCHARGE $5.0 �h permit. �
❑ SAC CHARGE @ $�
���/
TOTAL "�' �S
OTHER CHARGES (IF APPLICABLE) pAY TO UTILITY BIL G
N$W WATER METER COST - SEE UTILITY BILLING
SPECIAL ASSESS,MENTS - SEE FINANCE
WATER TAP - SEE ENGINEERING
NOTE: WATER METER REPAIR, INSP OR SHUT-OFF / EVENING3, WEEKENDS & HOLIDAYS $125/HOUR-BILLED
; THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LJNTIL 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 permit an work is not to start without a permit. '
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SIGNATURE OF APPLICANT PRINT NAME: bATE: J� �"- 2
APPROVED BY: DAT'E: � �I C �
COPY GI N T :❑ uT ITY BILLING (only if new meter) ❑ 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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