P - 48350Engineering WATER AND SEWER Permit No.:201,�bCyl 'L�
763-572-3552 PERMIT APPLICATION Received By: N!�' �
763-571-1287 fax CITY OF FRIDLEY Da�e�'d� ��� �� ��
EFFECTIVE O1/O1/2011
APPLICATION DATE: ��� � Z YOUR E-MAIL/FAX:
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
JOB ADDRESS: /SSi 7S� ���_,C/�
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NA1v�:
TENANT ADDRESS: /SS-9 %S��'/�VG N,E CITY� <^��{/��/ STATE�ZIP�,�Z
PHONE:
CONTRACTOR NAME: d
SUBMITA COPYOF ADDRESS:__l�/,5�.�� Z7�'`'AyC �tJ CITY STATE
YOUR STATE �ZIP S.S' S��%
LICENSE WITH PHONE _7� �"SIJ� ��G^ �' CELL PHONE:
APPLICATION
STATE LIC # STATE BOND: EXP DATE:
1. Narrati written description: / / �./
�.��i— „��1.� ��– /h �ct .roL (O " 7 C�77i7 �i► 7
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations: �Se �cce����c �'�f„�o i..���k StG�n�ess s�eel 6aKds. Revl�re
�h �thG�erw►Tnt CkP6 fV` Sf+�e�f � � q ��`cq��e , US� �^o -?,/�
b�ck .l� � cow�puc�:o� w�e�-kodS, �al( Z in�s pn;d�. fo insp�'�f OH
PERMIT TYPE
❑ SEWER CONNECTION PERMIT ❑ SEWER DISCONNECT PERMIT $50
❑ WATER CONNECTION PERNIIT ❑ SEWER DISCONNECT PERMIT $50
❑ WATER LINE REPAIR $40
�EWER LINE REPAIR $40
❑ ADD STATE SURCHARGE $5.00 for each permit
❑ SAC CHARGE @ $�30 =
a3(a5 �
TOTAL $ ,�—�
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLIN
NEW WATER METER COST – SEE UTILITY BILLING
SPECIAL ASSESSMENTS – SEE FINANCE
WATER TAP – SEE ENGINEERING
NOTE: WATER METER REPAIR, INSP OR SHUT-OFF J 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 (new connection or repair) 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 an rk is not start without a permit.
SIGNATURE OF APPLICANT ` PRINT NAME: �/,j� ����i`r� DATE:
APPROVED BY: � DATE: �" 3 ��`� 2-
COPY G N TO: o uTiLi BILLING (only if new meter) ❑ PUBLIC WORKS ❑ ENGINEERING
t;ity of r'ridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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