P - 84379Engi eering WATER AND SEWER Permit No.:� U l.') �
763-�1�-�552 PERMIT APPLICATION Received By:
CITY OF FRIDLEY �����
763-571-1287 fax EFFECTIVE01/12/2012 D ��
APPLICATION DATE: / � /''�' YOUR E-MAIL/FAX:
THIS APPLICANT IS: ❑ OWNER �aCONTRACTOR
JOB ADDRESS: �.� "3 � � r = GU '4 `� �I�� .
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME: .4 r r n
OWNER/ ADDRESS: 2 3 ��� A `�L CITY STATE ZIP
TENANT
PHONE: � I 'Z. – cj `y C^ ^ � �i �
CONTRACTOR NAME: � n, QN--, ��.v—�-� � �-� ��
SUBMITA COPYOF ADDRESS: ���st.�.�� n/"'1 CITY �f�'+t,,•e�.—_ STATE ZIP SS� �( a
YOUR STATE � •
LICENSE WITH PHON��'� �-Q7 �. -�� i2 CELL PHONE: �a i y' 2-S ca � h� s' �^
APPLICATION
STATE LIC # STATE BOND: EXP DATE:
l. Will work take place in City ROW? Yes No If yes, ROW registration is required — see Engineering.
2. Provide written description of proposed work: 1�2-�0 0�..�.= g,u,�,�..,� 5,,.�.�,�s-,
�� �-i " X % " c.crv, �. � � r v �.-�,
3. Attach plan/sketch showing proposed work with existing curb, utilities, trees, buildings, etc. with dimensions
4. Circle type of erosion control measures to be installed to prevent disturbed soils from eroding:
Silt Fence Bio-rolls Erosion Blanket Sodding Other:
5. Provide minimum of 2 hr notice for inspection ( 8 am — 4:30 pm) and call in the following order: (763) 572-
3552, (763) 572-3551, (763) 238-8048, (763) 572-3562 or (763) 572-3566, or (763) 427-1212.
6. Refer to "Construction Requirements for Water and Sewer Work" on back of page.
7. Stipulations:
PERMIT TYPE
❑ SEWER CONNECTION PERMIT ❑ SEWER DISCONNECT PERMIT $50
❑ ATER CONNECTION PERMIT ❑ WATER DISCONNECT PERMIT $50
SEWER LINE REPAIR J WATER LINE REPAIR $40 D
0 ADD STATE SURCHARGE $5.00 for each permit �
� SAC CHARGE @ $2365 =
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 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 a perm�t but only an application for a permit and
work is not to start without city ap roval of this p rmit application, unles emergency repair is required.
SIGNATURE OF APPLIC PRINT NAM ✓' L �'2o`%�j DATE: �Or / /
APPROVED BY: DATE: U I�
COPY GIVE �: � UTILITY BILLING (only if new meter) ❑ PUBLIC WORKS ❑ ENGI E RING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
Revised 10/12
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