P - 74932CITY OF FRIDLEY ��` � �����
WATER AND SEWER CONNECTION PERMIT
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APPLICATION
Name: l t� LLY r SC� IJ 7� C;11 � S Date: �- a� 199�-
(Home Owner or Plumber)
Job Address: � � �' � � /� ��",
LOT NO. OCK TRACT OR ADDITION
LEGAL DESCRIPTION �� � � � J�-�� �vU� ��r�
PERMIT: �. /
SEWER: WATER: METER:
L
FEE: �`S � FEE: ''' " �U DEPOSIT:
O•DAPTE R :
STATE �� STATE �S�
SURCHARGE: T SURCHARGE:
TOTAL: �—�` t U TOTAL: `� � J TOTAL:
'�"`�/ �c>
GRAND TOTAL:
S.A.C. CHARGE ON EXISTING STRUCTURE:
EXISTING STRUCTURE: NEW STRUCTURE:
BUILDING PERMIT No.: ���09 SEWER/WAT R PERMIT I)10.:
SPECIAL ASSESSMENTS: �' Signed `�"'r �a�`��
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