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P - 74933
CITY OF FRIDLEY WATER AND SEWER CONNECTION PERMIT APPLICATION �- yy a y� � J !C' K,(.)��2- �c-c , C_p� f �S Date: � - �L' —19�,� (Home Owner or Plumber) Job Address: � U a� ��� f � v� ��- LOT NO. BLOCK TRACT OR ADDITION IEGAL DESCRIPTION � � ����,���� � �1����� PERMIT: �,vn ,9,�;),v SEWER: "�� FEE: �S UU WATER: / METER: FEE: S UU DEP061T: O-DAPTE R : SU C ARGE: 5� SU CHARGE: �� � � TOTAL: '' � TOTAL: �� `' U TOTAL: � GRAND TOTAL: �/� G� S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: NEW STRUCTURE: BUILDING PERMIT No.: SEWER/WATER PERMIT � �j �0.:� SPECIAL ASSESSMENTS: �'"�u �, f 1`� w ._ Signed: � gy; � —��--� —� ,� ,� zv .