P - 84377Engineering WATER AND SEWER Permit No.: `
763-572-3552 PERMIT APPLICATION Received By:��
763:7 CITY OF FRIDLEY _� ,��
-� / 1-1287 fax EFFECTIVEOUl2/2012 ��e����
APPLiCATION DATE: I� I l 5��� YOUR E-MAIL/FAX: _
THIS APPLICANT IS: ❑ OWNER �'CONTRACTOR
JOB ADDRESS: ��= "� � S � � � iLI �'°
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME: G- o' � �~� d- ^ n
��A� ADDRESS: S�— � �► � L' �Av-E RJ � CITY "7 n� STATE ZIP
PHONE: �P 1"'L- �"� p^ 3 2 3 5
CONTRACTOR NAME: ( c� � "f"�� � �-,� �-� �-�` L
SUBMITA COPYOF ADDRESS: �") 'j" ��� cf�irc. (��'j CITY�A��1� -.ft L_ STATB�ZIP SS 4 L.1 p
YOUR STATE
LICENSE WITH PHONE ��� �('! �•. (2 "> 1'L— CELL PHONE: Cc 1'1- 'Z S d ��+ 3 rt 'S`
APPLICATION
STATE LiC # 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: ��,f� �� e .��,c.� s�� h<��, ..� � S� n
� P.s�O � g. e C. '� �.c1 � e� ,P. D^E �4 r c c� .
3. Attach�ketch 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) 572-3562 or (763) 572-3566, or (763) 427-1212.
6. Refer to "Construction Requirements for Water and Sewer Work" on back of page.
7. Stipulations:
PERMIT TYPE
❑ SEWER CONNECTION PERMIT [-; SEWER DISCONNECT PERMIT $50
❑ WATER CONNECTION PERMIT �7J� ATER DISCONNECT PERMIT $50
❑ SEWER LINE REPAIR GY WATER LINE REPAIR $40
❑ ADD STATE SURCHARGE $5.00 for each permit �
�.� SAC CHARGE @ $2365 =
TOTAL $ S �
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 permit but only an application for a permit and
work is not to start without i oval t ermi application, unless emergency repair is required.
SIGNATURE OF APPLICANT ���� � PRINT NAME• ✓`ti N U�' � DATE: /� / ���
�
APPROVED BY: DATE: I � � J ��
COPY GIVE �: ❑ UTILITY BILLING (only if new meter) ❑ PUBLIC WORKS ❑ ENGIN ER NG
City of Fridley j
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
Revised 10/12
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