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P - 74945CITY OF FRIDLEY WATER AND SEWER CONNECTION PERy1IT APPLI�ATION ' Name: � �< < <=-� Job Address: L LEGAL DESCRIPTION PERMIT: Owner or Plumber� / — (p � � c,�".. .�-- SEWER: � WATER: FEE: °1�� FEE: �� UU ,�..�� 7°y ,�/ Date: �� s 9a O-DAPTE H: STATE c"v STATE S � SURCHARGE: �`' SURCHARGE: ' TOTAL: �S `'U TOTAL: /S 'S v � GRAND TOTAL: �/.��U METE R: DEP061T: TOT L: S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: NEW STRUCTURE: BUILDING PERMIT No.: `� � 5�--� SEWER/WA ER PERMIT NO.: �� SPECIAL ASSESSMENTS: l'� Signed� � � ' � ' BY: %-°�--r__ �� , �