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P - 75029
..I,_'�'""�.r?�''M��'F'�"�T�i�:t'}`+S'1'�+T.�,t���^�.�,�-��g�,-'��.���;°'�S�u.'t!':t ,�„p..,,�Au•�y'Y'/.,."^_.Y��'e�r.i'ftf}�': .'4.��a'.5'V11�.< �� l(��� CITY OF FRIDLEY WATER AND SEWER CONNECTION PERMIT APPLICATION Name: � L� 2 t A-1 1�' S Date: �' 3� 19� �" Owr»r or eiurnbe�► Job Address: d�0 �� �T�'� l�-� L.•� � ��LOT �� I � 7 K I T7�J'J�R A/ �a LEGAL DESCRIPTION / � PEIR�MIT: � .. �--_ ✓ ✓ SEWER: WATER: ' METER: FEE: �i_/ FEE: �`�'' � ��/ DEP061T: O-DAPTER: SURC ARGE: �� SURCHARGE: � TOTAL: °`„ ' �`� TOTAL: ' �" " � TOTAL: GRAND TOTAL: y� G� S�A.C. CHARGE ON EXISTING STRUCTURE: ' EXISTING STRUCTURE: NEW STRUCTURE: BUILDING PERMiT No.: � U� SEWER/W ER PERMIT NO.: SPECIAL AS.SESSMENTS: Siq�d, /�-A"L LL�C� � ��' 8 ,