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Engineering WATER AND SEWER Permit No.:
763-572-3552 PERMIT APPLICATION Received By:
763-571-1287 fax CITY OF FRIDLEY Date Rec'd: `7
EF FECTI V E 0 I/01 /201 1
APPLICATION DATE: �" /�^ 7— l I YOUR E-MAIL/FAX _
TH[S APPLICANT IS: ❑ OWNER �ONTRACTOR
/ / 6 � /
]OB ADDRESS: �!v "— tC3 CG � 'Z C/L�''�I `�"I � SC `° •
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME: ��A r' � �, C- wi c�
OWNER/ ADDRESS: 1�O 6 ��- ��� �-I �- CITY � STATE ZIP
TENANT T—
PHONE:
CONTRACTOR NqME: � - t �
SUBMITA COPYOF ADDRESS: �7 S� ��%--t %�1 CITY N STATE Zl��� �-('f�
YOUR ST,9TE
LICENSE W/TH PHONE �� � � � �7 �' �(9"l � t CELL PHONE ,� � t- - "Z- � v ^ � � cl S—_ _
APPLICATION
STATE L1C # STATE BOND: EXP DATE:
l. Narrative/w tten description:
� �(° _.� � ��-, 5�.��.� /�G..� �3 �� X- `� �-�-� ��
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations: �i,�' �oJ' ►NSD�C�ti � v1 (�,t�� Dt/' ���C�'�' II�
Q��� �e�S �� �'y��C�Va�'�pv�.. �iSC'. �u�Pi��1- .,�GC�: �id," carhj����,:t��1
�{�I��e� 5�:�1 ir ��+�`}S .
PERMTT TYPE
❑ SEWER CONNECTION PERMIT '� SEWER DISCONNECT PERMIT $50
_l WATER CONNECTION PERMIT '-', SEWER DISCONNECT PERMIT $50
^ WATER LINE REPAIR $40
_ SEWER LINE REPAIR $40
[l ADD STATE SURCHARGE $5.00 for each permit r '
❑ SAC CHARGE @ $2230 =
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 SHIJT-OFF / EVENINGS, wEExENDS & HoLtDaYS $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LJNTIL 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 conformance with the ordinances and codes of the City of Fridley. I understand this is not a permit but
only an application for a permit work is t to s�rt without a pennit.
SIGNATURE OF APPLIC T � ��?�"'�"`�/ PRINT NAME. \"�'�` ✓' �l�cui� DATE: ': _ 'i- / /
APPROVED BY: DATE: �--. (� '- �I
COPY GIVE �: '7 UTILITY ILL NG (only if new meter) � PUBLIC WORKS - ENGINEERING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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