P - 48290Engineering WATER AND SEWER Permit No.2
763-572-3552 PERMIT APPLICATION Received By:�
763-571-1287 fax CITY OF FRIDLEY Da�' .�
EFFECTIVE Ol/O1/20] i ,
APPLICATION DATE: .���ZI���� YOUR E-MAIL/FAX: _
THIS APPLICANT IS: ❑ OWNER �CTOR
JOB ADDRESS: O�/ C9 f- lv r7 =��'@ �°
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME: s6J15 �7 � �� "�
OWNER/ ADDRESS: .�/O ^ ,6 °� '��' �"�-� 't �� CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR NAME: ^
SUBMITA COPYOF ADDRESS: `7 ?� l� �T �'7 CITY��(�'i'!9-e �-/ STATE ZIP
YOUR STATE
LICENSEWITH PHONE�'7�� L��Tr '67/ � CELLPHONE: �i 2- -2 5or^ �3g�
APPLICATION
STATE LIC # STATE BOND: EXP DATE:
1: Narrative/written des/cription: �[� �^
L1�/.rI���Y" � .IO`�. K ' /7�LI S ly Sr � � c�.. (� �'��T r�� � � � y
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2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations: Cui SL P�'b��.ly f�mAa�'��D� 0��� �aCK�°�� Yv1'2�'��1�5
O ✓�I,1 �UIV•G�1✓��,� e �a�� (.���� ��let �O ���i����'ON �
PERMIT TYPE
0 SEWER CONNECTION PERMIT ❑ SEWER DISCONNECT PERMIT $50
0 WATER CONNECTION PERMIT ❑ WATER DISCONNECT PERMIT $50
❑ WATER LINE REPAIR $40 (7
0 SEWER LINE REPAIR $40
❑ ADD STATE SURCHARGE 55.00 for each permit
�J SAC CHARGE @ $2230 =
TOTAL $ � ��
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING
NEW WATER METER COST — SEE UTILITY BILLING
SPECIAL ASSESSMENTS — SEE FINANCE
WATER TAP — SEE ENGINEERING
NOTE: WATER METER REPAIR, INSP OR SHUT-OFF / EVErTING5, WEEKENDS & HOLIDAYS $125/HOUR-BILLED
THIS IS AN APPLICATTON FOR A PERMIT-NOT VALID UN'fIL 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. I understand this is not a permit but
only an application for a pg it an ork is not to start without a permit.
SIGNATURE OF APPLICANT Q""� �.S- PRINT NA • � �/� � DATE: �' �D / /
APPROVED BY: DATE:
COPY GIVEN TO: ❑ UTILITY BILLING (only if new meter) ❑ PUBLIC WORKS C ENGINEERING
City oi' N'ridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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