P - 35825E���n, ering WATER AND SEWER Permit No.: ' '��3��
763-572-3552 PERMIT APPLICATION Received By:
763-571-1287 f2X CITY OF FRIDLEY Date����.��� �
EFFECTIVE Ol/OU20t 1
APPLICATION DATE: � �7rP��� YOUR E-MAIUFA�X: _
THIS APPLfCANT IS: ❑ OWNER �O�ry�CTOR
.IOB ADDRESS:
NEW CONSTRUCTION PERMIT# QF APPLI ABLE):
PROPERTY NAME:
OWNER/ ADDRESS: C1TY STATE ZIP
TENANT
PHONE:
CONTRACTOR NAM .
SUBMIT A COPY OF
YOUR STATE �DRES :
LICENSE WITH PHON ' `' CELL PHONE: '
APPLICAT/ON
STATE LIC #1 STATE BOND: EXP DATE:
l. Narr ive/ ritten descri ion• v �
2. ease attach sketch s owing curb tine, utility line, building, etc. with distances on back page.
3. Stipulations:
/
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2. f.�� ����.,.,� � � ,��� P,`,�,.Q
3r I'��� � G� Y�� � �
I' SEWER CONNECTION PERMiT I SEWER DISCONNECT PERMIT $50
I.:; WATER CONNECTION PERMIT i WATER DISCONNECT PERMIT $50
� �I WATER LINE REPAIR $40
MI SEWER LINE REPAIR $40 O
I; ADD STATE SURCHARGE $5.00 for each permit �
I SAC CHARGE @ $2230 =
TOTAL $ '�-t�� �
OTHER CHARGES (IF APPLICABLE) PAY TO UTTLITY 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 & HOL(DAYS $125/HOUR-BILLED
THIS IS AN APPLIC.ATION FOR A PERMIT-NOT VALID UNTIL 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 confo ance with the ordinances and codes of the City of Fridley. 1 understand this is not a permit but
only an application for a per ' an k is t t st ' out a permit.
SIGNATURE OF APPLICANT INT NAM DATE: �I �
APPROVED BY: DATE: Z 1�
COPY GIVEN 0� ; UT ITY LLING (only if new meter) C_i PUBLIC WORKS C] ENGINEERING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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