P - 84378Engineering WATER AND SEWER Permit No. �� L7�
76�-`,�Z-3552 PERMIT APPLICATION Received By:��,
763-571-1287 fax CITY OF FRIDLEY Dat��d��'�` ������
EFFECTIVE O1/12/2012
APPLtCATION DATE: �/ -rt // '�-- YOUR E-MAIL/FAX: _
THIS APPLICANT IS: ❑ OWNER ❑ CONTRA�TOR /�� �
JOB ADDRESS: '� / a � � � � �`7�(d-Q. M t%
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY N,�tv1E: ry +�
OWNER/ ADDRESS: �% y O �j ��► �� nJ � CITY STATE ZIP
TENANT
PHONE: � I '�- - S � d °— � '�I � %
CONTRACTOR N�1vtE: � �v-Y � C�3
SUBMlTA COPYOF ADDRESS: 'i � Rb �+�✓--� V�� CITY /`Via-VV� �- L- STAT ZIP_-�s � Y(j
YOUR STATE �
LICENSE WITH PHONE�"( (�'3 �I '7 �- �e1 � 2 CELL PHONE: �1 'L - Z�S d^ 6 3 ci.J"--'
APPLICATION
STATE L1C # STATE BOND: EXP DATE:
1. Will work take place in City ROW? Yes No If yes, ROW registration is required — see Engineering.
2. Provide written description of proposed work: , r�1L-R..n Y�a � h
C. � r- f� � U X °� S� E9-r► C� Y' i �o ae..,
3. Attach plan/sketch showing proposed work with existing curb, utilities, trees, buildings, etc. with dimensions
4. Circle type of erosion control measures to be installed to prevent disturbed soils from eroding:
Silt Fence Bio-rolls Erosion Blanket Sodding Other:
5. Provide minimum of 2 hr notice for inspection ( 8 am — 4:30 pm) and call in the following order: (763) 572-
3552, (763) 572-3551, (763) 238-8048, (763) 5�2-3562 or (763) 572-3566, or (763) 427-1212.
6. Refer to "Construction Requirements for Water and Sewer Work" on back of page.
�. Stipulations:
PERMIT TYPE
`.� SEWER CONNECTION PERMIT C� SEWER DISCONNECT PERMIT $50
❑ WATER CONNECTION PERMIT ❑ ATER DISCONNECT PERMIT $50
❑ SEWER LINE REPAIR WATER LINE REPAIR $40 �
� ADD STATE SURCHARGE $5.00 for each permit
� SAC CHARGE @ $2365 =
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 /(EVENINGS, WEEKENDS & HOLIDAYS � $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a water or sewer 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 per►nit but only an application for a permit and
work is not to start without city ap roval of this permi application, unless emergency repair is required.
SIGNATURE OF APPLICAN PRINT NAME� ►� 4 DATE: �% Pi�
/'
APPROVED BY: DATE: I
COPY GIVEN :❑ UTILITY LING (only if new meter) ❑ PUBLIC WORKS ❑ ENGIN ERING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
Revised 10/12
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