P - 43692/
Engineering WATER AND SEWER Permit No.:
763-572-3552 PERMIT APPLICATION Received By:
763-571-1287 faX CITY OF FRIDLEY Date Rec'd: s��' !/
EFFECTIVE 01 /O l /2011
PeP'PLICATION DATE: � f� YOUR E-MAIL/FAX:
THIS APPLICANT IS: "❑ OWNER ❑ CON�RACTOR
70B ADDRESS: �� 2 Z u�� �/
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAM�:
OWNER/ ADDRESS: CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR NAtvtE: � � �' 'o! l��i -' P +''`-
SUBMIT A COPYOF ADDRESS: "7 % S ��? �zJ � r �� •1 CITY� Vl� P- f STATE Z[PSS � yd
YOUR STATE `
LICENSE WlTH PHONE ~�,�, � � 7 � � `) ! `L CELL PHONE: 4s ! '�- ' �� S t• - 4: - � S �—
APPLICATION
STATE LIC #>�� ��/i!1 STATE BOND: EXP DATE:
1. Narrative/written des iption: , �
�� �!-i ,C i-z :� I C �� v.w ' � S � U' �7 � � �_ /�4- '�'' C � �rF� f j x �
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations: � � � �
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✓Cy.e� �
� �y�,�.y��ye PERMIT TYPE
� SEWER CONNECTION PERMIT � SEWER DISCONNECT PERMIT $50
❑ WATER CONNECTION PERMIT C; SEWER DISCONNECT PERMIT $50
�Ri WATER LINE REPAIR $40 � l�lS
`. SEWER LINE REPAIR $40
�ADD STATE SURCHARGE $5.00 for each permit ,��"." d p
❑ SAC CHARGE @ $2230 =
� TOTAL $ ��'
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OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLIN
NEW WATER METER COST — SEE UTILITY BILLING
SPECIAL ASSESSMENTS — SEE FINANCE
WATER TAP - SEE ENGINEERING
NOTE: WATER METER REPAIR, INSP OR SHlJT-OFF / EVENINGS, WEEKENDS & HOLIDAYS $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VAUD 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 cg ormance 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 n�to sta without a permit. -
SIGNATUREOFAPPLICA�FIT .��" �V f-/LG""' `� . PRINTNAME:f7�'�N✓�C-j�i`DT"� DATE: � �C
APPROVED BY: DATE: � � � I�
COPY GIVE :❑ ILITY BILLING (only if new meter) ❑ PUBLIC WORKS '�_� ENGINEERING
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t.l 1.,' V l 1' l lU 1G,' '
' Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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