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 $
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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
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