P - 48079Engineering
y 6`�-572-3552
763-571-1287 fax
APPLICATION DATE: _
THIS APPLICANT IS:
JOB ADDRESS: _�
NEW CONSTRUCTION
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WlTH
APPLICATION
WATER AND SEWER
PERMIT APPLICATION
CITY OF FRIDLEY
EFFECTIVE O1/O1/2011
YOUR E-MAIL/FAX: �� • ��'=-S"r
❑ OWN�R �.CONTRACTOR
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MIT# (IF APPLICABLE):
NAME: �G'��-G� �
ADDRESS: I �t2 �d-I�- F��/E
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Permit No.:
Received By:
Date Rec'd: – — �
�2Z�C ��-1 STATEIN�A�IP
ADDRESS: Z.Z.���JF�'r{? P�_ CITYST i�r4( AL STATE W�JZIP�1�
PHONE �,cjj�tS-Ei�'Z? CELLPHONE: �1,J� G--,1'Z,-Lfqp_�'�-��°r
STATE LIC #��� `�5��� STATE BOND: EXP DATE:
L Narrative/written description:
(,��—C'�r, f�-- 1��2��-�e a F �-l'� Z_ �rL -rr-�.o..._
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations:
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PERMIT TYPE
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❑ SEWER CONNECTION PERMIT ❑ SEWER DISCONNECT PERMIT $50
❑ WATER CONNECTION PERMIT ❑ WATER DISCONNECT PERMIT $50
ATER LINE REPAIR $40
��SEWER LINE REPAIR $40
DD STATE SURCHARGE $5.00 for each permit
0 SAC CHARGE @ $2230 =
,n• �r� �
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 SHLJT-OFF / EVEI�TINGS, WEEKENDS & HOLIDAYS $125/HOUR-BILLED
THIS IS AN APPLICAT[ON FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a water or sewer (new connection or repair) per►nit 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. J understand this is not a permit but
only an application for a permit and work is not� start without a permit.
SIGNATURE OF
APPROVED BY:
COPY GIVEN
._--
.i
GITY BII�L,ING (only if new meter) ❑ PUBLIC WORKS
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
DATE: I t
DATE: Z r
C ENGINEERI G
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