P - 42102Engineering WATERANDSEWER PermitNo.:LEJ — �"
763-572-3552 PERMIT APPLICATION Received By:
763-571-1287 fax CITY OF FRIDLEY ���
EfiFECTIVE01/O1/2011 �i�� +� 1i� �A9
APPLICATION DATE: �� I�' LO Z � YOUR E-MAIL/FAX: (�, �` ���'� j" A 1 VI 'l l�� J V► (d _ G ��
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR �
JOB ADDRESS: 6 ��{ I � � 5t • /��' Fr %�1 �c �- '
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME: R r 1'an I�e; L�„r+
OWNER/ ADDRESS: L� I LI � S� Sf � N�i CITY �Y�G' �,{,v� /i/(.,/V STATE /��/ZIP�'Z
TENANT ��-i_ -�-,�_ ,�.i,...
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITN
APPLICATION
NAME: s p� i n
ADDRESS: � 7 N � LG y► r� � CITY �y �c�, v� � STATENL�LIP S ��
PHONE _7�3" ��G' 3 O I9U CELL PHONE: �
STATE LIC # � �, � I ( r �M ST'ATE BOND: �SI �c � �' � EXP DATE: lLt 3 � ��p �J
r
1. Narr$ative/writt{e�n� description: / q /
�1�(�4�✓' RLp � CQ. y�� 5a »l�hi✓'� ��Ir f/ nR, F�rr, /Qr��if pY l,t�sb'Z. � C
� hee.da.�. 4le don� �ie+L�nou. eX�.c%l� w lu„ �� l�ro ldr, � s�
2. Please attach sketch showing curb line, utility line, uilding, etc. with distances on back page.
� �� 3� Stipulations: � o ��(/ ��t�i't��tvlv� � �e���- l Z�/l%T��c.Q�
0
3
(�TCO,
0
7y' C�— u.�% � . S. � 7(,�,�9� °Z es�°.c.ti,r�-`
�12' y�,v � 3`� � �`' �. s � � �'
�Z o`�� !'.) • � . � s P R IT'�'Y E , � � � / -
5 ��6 � � � c,�.t�
� �-�D ��
�j ❑ SEWER CONNECTION PERMIT C SEWER DISCONNECT PER T $50
C� ❑ WATER CONNECTION PERMIT ❑ SEWER DISCONNECT PERMIT $50 � '
❑ WATER LINE REPAIR $40
�WER LINE REPAIR " $40
L AD STATE SURCHARGE $5.00 for each permit .S^
, ❑ SAC CHARGE @ $2230 =
. ._...lr �
� � � � � � TOTAL � �j �
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLI G
NEW WATER METER COST - 3EE UTILITY BILLING
SPECIAL ASSESSMENTS - SEE FINANCE
WATER TAP - SEE ENGINEERING
NOTE: WATER METER REPAIR, IN�P OR SHtJT-OFF! EVENINGS, WEEKENDS & HOLIDAYS $125/HOUR-BILLED
THIS IS AN APPLICATION 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
accurate; that the work will be in conformance with the ordinances and codes of the City of Fridley. I understand this is not �permit but
only an application for a permit and r�s not to start without a permit.
SIGIVATURE OF APPLICANT �7715a ���L�(/�V � PRINT NAME: /T �T �L V lG yV �� DATE: ���7� � ��
APPROVED BY:
1
COPY GI T:❑/ TY LLING (only if new meter) �I PUBLIC WORKS
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
DATE: � 'l � `I
:_ � ENGINEERING
� '
N �
•, �
� �
�
, .
;
� ,/- ReJ����r�Rtp�a2 as h� '
1�
Cvrb '
�
� ,
,
M�.,I�,k � ' � `
,..- . _____- -----
,�-1'� �-f . A,l�
�
"I ,
..
�--�
�
�+ � �
� , r �
' � � � � � ''� � �(� �
�- �-------- ,� r . �l ,L
���� �
, __-_- � °
�
,.
��
���