P - 41751Engineering WATER AND 5EWER Permit No.: '� j
763-572-3552 PERMIT APPLICATION Received By:
763-571-1287 fax CITY OF FRIDLEY DatR�dn��.t�2Q
EFFECTIVE 01/01/20I 1
APPLICATION DATE: I�� � I YOUR E-MAIL/FAX:
THIS APPLICANT IS: ❑ OWNER �CONTRACT/O'R'
.IOB ADDRESS: _ _ ����,_�� � h � �L//4 ��
NEW CONSTRUCTION PERMIT# (IF APPUCABLE):
PROPERTY NaME: f'� � '�' � � �°
OWNER/ ADDRESS: CITY STATE ZiP
TENANT
PHONE:
CONTRACTOR NAME: b --
SUBMIT A COPY OF
YOUR STATE ADDRESS: �'L � CITY � STA ZIP��N �
LICENSE WITH PHONE �(� �--� �i�-"� �� � Z-- CELL PHONE: lo /'Z - Z S O—�O 3 S�
APPLlCATION
STATE LIC # STATE BOND: EXP DATE:
l. Narrative/wr' ten escription:
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2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations: �/2.2i'��� �:CMJ� . C.�� � '
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PERMIT TYPE "'3'j SZ
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I' SEWER CONNECTION PERMIT l SEWER D[SCONNECT PERMIT $502� T 8 � se
I. WATER CONNECTION PERMIT I WATER DISCONNECT PERMIT $50
I WATER L[NE REPAIR $40 ldL�
I SEWER LINE REPAIR $40
I; ADD STATE SURCHARGE $5.00 for each permit
i SAC CHARGE @ $2230 =
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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, [NSP OR SHUT-OFF / EVENINGS, WEEKENDS & HOLfDAYS $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 wilt be in co ormance with the ordinances and codes of the City of Fridley. I understand this is not a permit but
only an application for a it ork is to sta without a permit.
SIGNATURE OF APPLIC�IT PRINT NA `'�/' �L/!�� / l DATE: �/ �
APPROVED BY: DATE: �� l
C�P� G T: f' iLITY BILLING (only if new meter) l� PUBLIC WORKS l�' ENGINEERING
(".itv nf Fricllev
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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