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P - 74930CITY OF FRIDLEY WATER AND SEWER CONNECTION PERMIT APPLICATION � �s a` i" Name: �� C � �U S- � < <� � !15 Date: �-3 - /� 19 ��- (Home Owner or Plumber) Job Address: / G i / -- <� � ' `' f � :�� LOT NO. BLOCK .� TRACT OR AD�ITION LEGAL DESCRIPTION - -�-- � /�d?��//Hf-L =��/�c��%L�S - PERMIT: SEWER: � J WATER: METER: FEE: �� OO FEE: �� OO DEP061T: _-1 O-DAPTER: STATE i � STATE , SJ SURCHARGE: ' '-' SURCHARGE: �-- r - [ ` C� -, TOTAI: "�'- � L� TOTAL: �'' �� TOTAL: GRAND TOTAL: �,�i �o S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: NEW STRUCTURE: BUILDING PERMIT No.: -� �� SEWERNyATER PERMIT NO.: ��' �'1 � SPECIAL ASSESSMENTS: � Signed% %��'� a d `" �' � �"� �<—,- gy; ,'`�_--> .1/ .- � w