P - 74942CITY OF FRIDLEY
WATER AND SEWER CONNECTION PERMIT
APPLICATION
V
Name: � � Date: 9" �� 19 � �
(Home Owner or Plumber)
Job Address: �� �--j — � `� �� %�% � ��
LOT NO
LEGAL DESCRIPTION /,c..�
PERMIT:
SEWER: '�'
FEE: °� S UU
BLOCK TRACT OF
/ SP�1n.�(o
WATER: "� METER: ��
FEE: �S DO DEP061T:�
O-�APTER:
STATE �� � •. STATE , S O
SURCHARGE: SURCHARGE:
TOTAL: °z�''� TOTAL: ��'� TOTAL: �Q' �
S
��0� Oc4�y,� GRAND TOTAL: �/O�. a v
S.A.C. CHARGE ON EXISTING STRUCTURE:
EXISTING STRUCTURE: NEW STRUCTURE:
BUILDING PERMIT No.: SEWER/WATER PERMIT NO.:�L.1.t�.
SPECIAL ASSESSMENTS: � �?s Signed:l� � �3. M i /1 � .� PI �> � ! •11-�� I_'- � c
By: ���-�. ;;: i . �c��_