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P - 43655�: E�K �� eering WATER AND SEWER Permit No.: iub 3 "/ 72-3552 PERMIT APPLICATION Received By:�(�!'��____ 7-�3-571-1287 fax CITY OF FRIDLEY Dat� Rec'd: EFFECTIVE 10/27/2010 APPLICAT(ON DATE: 2 YOUR E-MAILlFAX: — THiS APPLICANT tS: OWN R C:jeSNT CTOR JOB ADDRESS. � �D �+' � " // �' e � � NEW CONSTRUCTION PERPci(T# ((F APPL,fCABLE}: PROPERTY NAME: � OWNER/ ADDRESS: � CITY STATE ZIP TENANT PHONE: CONTRACTOR NAME. SUBMITA COPYOF ADDRESS: !/ TATE�,�%Z- YOUR STATE LICENSE WITH PHONE %��,�D��S� CELL PHONE: �� APPLICAT/ON STATE LIC q STATE BOND- EXP DATE: 1. Narrative/written descriPtion: __ // C=T�c�n+ a�� �' Ji�,D Gf? St'�.Y� �d��GP rG 'Z'�� '�iYlv 2. Please attach sketch showing curb tine, utility line, building, etc. with distances on back page. 3. Stipulations: PERMIT TYPE ❑ SEWER CONNECTION PERMIT _: � SEWER DISCONNECT PERMIT $50 l WATER CONNECTION PERMIT !:-', SEWER D[SCONNECT PERMIT $50 �}�' ATER LINE REPAIR $40 LM' SEWER LINE REPAIR $40 I:; ADD STATE SURCHARGE $5.00 for each permit 0 SAC CHARGE @ $2100 = ._ TOTAL $ �� OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY B(LLING NEW WATER METER COST— SEE UTIL[TY BILLING SPECIAL ASSESSMENTS — SEE FINANCE WATER TAP — SEE ENGINEERING � NOTE: WATER METER REPAIR, INSP OR SHCJT-OFF 1 EVENINGS, WEEKENDS & HOLIDAYS $125/HOUR-BILLED TH[S IS AN AAPLICATION FOR A PERMIT-NOT VALID UNTIL 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. [ understand this is not a permit but only an application for a perm' wor}C � n t art without a permit. SIGNATURE OF APPLICAN I�%�� PR[NT NAM�✓� f�l/t���-r%r" DATF�2 ''Z �d �.. APPROVED BY: DATE: COPY GIVEN �O: � UTILITY BILLING (only if new meter) !�l PUBLIC WORKS �! ENGINEERING c,ity ot r ria�ey Engineering Department 6431 University Avenue NE, Fridley, MN 55432 763-572-3552 FAX: 763-571-1287 � �63 �7/-8��`9 �- 1 1 � � // / : /