P - 43179Engineering WATER AND SEWER Permit No.:
763-5%2-3552 PERMIT APPLICATION Received B:
763=571-1287 fax CITY OF FRIDLEY ,���� 3� 2010
EFFECTIVE 7/1/2010 �
APPLICATION DATE: ��:` �'` -5 � f i, YOUR E-MAIL/FAX:
THIS APPLtCANT IS: ❑ OWNER �ONTRACTOR
JOB ADDRESS: '�S �� 2. G(.?,� �� /`� , E
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME: � �e c. ;� c, �_ '}' � 1' �. . � � , �,� r, 5 � �1
OWNERI �� L Z w,�� �� � CITY �% +` C� �..Q �/ STATE ZIP
TENANT �DRESS: `-t � +
PHONE: ��. �^ S 7�— S 7 5`! �
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CONTRACTOR NAME: ` � ���`N�-� S .�--, � �-%«`���
SUBMIT A COPY OF �DRESS: ��� i� -�+--' � �%''� CITY -�'� R STATE ZIP SS �� D
YOUR STATE
LICENSE WITH PHONEwZ�� �i �"�� � 2 CELL PHONE: �� 7- � Z So- �� S�
APPLICATION
STATE LIC # STATE BOND: EXP DATE:
1. Narrative/written description: , �
Qp1p ,q, �,P� l-� R K �.n w�.:� e�, c� .P v. �� c-L. � v� � .
2. Please attach sketch showing curb line, utility line, build'ng, etc. with distances on back page.
3. Stipulations: .. !�� � ��•
Z � � �'' ,. --� � 7� -S' - 5Z
PERMIT TYPE
❑ SEWER CONNECTION PERMIT $50
❑ WATER CONNECTION PERMIT $50
❑ WATER LINE REPAIR $40
� SEWER LINE REPAIR $40
� ADD STATE SURCHARGE $5.00 'SDU
❑ SAC CHARGE @ $2100 =
TOTAL $
��� =
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING
NEW WATER METER COST — SEE UTILITY BILLING
SPECIAL ASSESSMENTS — SEE FINANCE
WATER TAP — SEE ENGINEERING
NOTE: WATER METER REPAIR, INSP OR SHUT-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 wark 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 ermit an ork is�,pt to start without a permit.
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SIGNATURE OF _'� ..- ~ %�iR-`�`'" � PRINT NAM�r � DATE: � / O
APPROVED BY: � DATE:
COPY G N T0: ❑ UTILITY BILLING (only if new meter) ❑ PUBLIC WORKS ❑ E�IGINEERING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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