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P - 74935
CITY OF FRIDLEY� ✓ WATER AND SEWER CONNECTION PERMIT APPLICATION Name: (Home Owner or Plumber) Job Address: � d a" %�S i � LEGAL DESCRIPTION Date: � - � 19�� OR PERMIT: / //��¢�O�Z SEWER: ✓ WATER: ✓ METER: FEE: aSOV FEE: �sUO DEPO6IT: 0•OAPTE R : SURCHARGE: ' �U SURCHARGE: - SO �- !� TOTAL: S'� TOTAL: �'� ' '' TOTAL: ��/ � GRAND TOTAL: S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: NEW STRUCTURE: BUILDING PERMIT No.: _°�� a�°� SEWER/WATER PERMI� 0.:��= SPECIAL ASSESSMENTS: �� � Signed: ``''O�'t' sO� �"�-� �►� U � ��' BY: �:%, ;,/��""- .