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Engineering WATER AND SEWER Permit No.. j� :�
7�3`=�72-355.2 PERMIT APPLICATION Received By:
763-571-1287 fax CITY OF FRIDLEY Dat� '�'dA �� ����
EFFECTIVE OU01/2011
APPLICATION DATE: T/�C� �, YOUR E-MA1L/FAX: _
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
.IOB ADDRESS: _ ��� �J� � %�C. YV� ��
NEW CONSTRlJCTION PERMIT# QF APPL]CABl,E):
PROPERTY NAME: `'^ �Z . c la�
OWNER/ ADDRESS: 7'� I �� � 1� Y 'l"�^ STATE �LIP
TENANT
PHONE: %(�,7 � „�'?! .- Coj��y,�
CONTRACTOR NAME: �+K�S ��a�C s�v✓ �wv�
SUBMlT A COPY OF '� /L��
YOUR STATE ���ESS: �� 3k C'� ir �.+-�. „J.X=- C�7'y / ��lii+� ��' :(_STATE �°`�ZIPS�ii
LICENSE WITH PHONE Gt � Z- r]df ' 3 7� 7 CELL PHONE: �� Z•??„� Z.�°Ga ")
APPLICATION
STATE LIC # STATE BOND: EXP DATE:
1. Narrative/written description:
�`'�� ,.. �-� /�� iL� y� '
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
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3. Stipulations: !•� TZ2.Q� , z. 1
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PERM IT TYPE
I' SEWER CONNECTION PERMIT t SEWER DISCONNECT PERMIT $50
I.:; WATER CONNECTION PERMIT i WATER DISCONNECT PERMIT $50
I WATER LINE REPAIR $40
I SEWER LINE REPAIR $40 1�l� -�"'
I: ADD STATE SURCHARGE $5.00 for each permit �,� �'
i SAC CHARGE @ $2230 =
�—
TOTAL $ � �
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING
- NEW WATER METER COST - SEE UTILITY BILLING
SPECIAL ASSESSMENTS - SEE FTNANCE
WATER TAP - SEE ENGINEERING
NOTE: WATER METER REPAIR, INSP OR SHUT-OFF / EVENINGS, WEEKENDS & HOLIDAYS $125/HOUR-BILLED
TH1S IS AN APPLICATION FOR A PERMIT-NOT VALID UNT1L 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. 1 understand this is not a permit but
only an application for a permit � is not to start without a permit.
SIGNATURE OF APPLICANT PRINT NAME: ��J'�-�- DATE d!
APPROVED BY: DATE: � Z�
COPY GI T�: ; UTILIT BILLING (only if new meter) i_� PUBLIC WORKS f-] ENGINEERING
� _.___City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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