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P - 48310Engineering WATER AND SEWER PermitNo.: 20 -od/ f 763-572-3552 PERMIT APPLICATION Received By:__�z'P_ 763-571-1287 fax CITY OF FRIDLEY Date Rec'd: 2— EFFECTIVE O1/12/2012 APPLICATION DATE: �- `' �GI � YOUR E-MAI� i(I! /� � � c� ^l � �D _ THIS APPLICANT IS: ❑ OWNER� �.CONTI�ACTOR 1 JOB ADDRESS: �II �� '� � � �! r � � NEW CONSTRUCTION PERMIT# (IF APPLICABLE): PROPERTY NAME: fU OW�� ADDRESS: ` l�- V'� CITY � STATEl�IP�� t/.�.� TENANT PHONE: CONTRACTOR NAME: GCi� tUC� SUBMIT A COPY OF �DRESS:�� SI�E LL' ll1JG� CITY��_S STATE��LIP_ �'s �� YOUR STi1 TE F=, / LICENSE WITH PHONE �f � � JiJ?� ^ '�' '7 7 (� CELL PHONE: /2 - �� :S� [ ..5� �I�/Q/� APPLICATIDN /� STATE LIC # G L� STATE BOND: EXP DATE: 1. Will work take place in City ROW? es o If yes, ROW registration is required - see Engineering. 2. Provide written des�ription of proposed work: ' 3. Attach plan/sketch showing proposed work with existing curb, utilities, trees, buildings, etc. with dimensions 4. Circle type of erosion control measures to be insta.11ed to prevent disturbed soils from� groding: Silt Fence Bio-rolls Erosion Blanket Sodding Other: V ,�.� � 5. Provide minimum of 2 hr notice for inspection ( 8 am - 4:30 pm) and call in the following order: ( 3) 572- 3552, (763) 572-3556, (763) 238-8058, (763) 572-3562 or (763) 572-3551, or (763) 427-1212. 6. Refer to "Construction Requirements for Water and Sewer Work" on back of page. ��'� � i 7. Stipulations: � �.--� - � ` PERMIT TYPE ❑ SEWER CONNECTION PERMIT ❑ SEWER DISCONNECT PERMIT $50 ❑ WATER CONNECTION PERMIT ❑ WATER DISCONNECT PERMIT $50 ❑ SEWER LINE REPAIR f�l , WATER LINE REPAIR $40 ❑ ADD STATE SURCHARGE $5.00 for each permit ' ❑ SAC CHARGE @ $2365 = TOTAL $ �J � 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 SHLJT-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 ordinanees 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 city ap rov 1 Qf 's permit application, unless emergency r pau is required. `; ` .-- ,�,/ �. SIGNATURE OF APPLICAN ° t�'� PRINT NAME: �%/ /%T� C-- DATE: � �—� APPROVED BY: DATE: %'J � �"' COPY G EN �: � UTILITY BILLING (only if new meter) ❑ PUBLIC WORKS ❑ ENGINEERING City of Fridley Engineering Department 6431 University Avenue NE, Fridley, MN 55432 763-5'72-3552 3� �� FAX: 763-571-1287 1 f� � i `� / � -..� V��✓ �� . � c a� �c�� l� � � � ��af��, `� � / � 0 � � �� ` �c�, l , � ► , � , � �'��-��- � �� ---�-.�==� �`�f�-�-- �,� � � � � � � ��.�-��- �' � � � �� / ► �- o � ��-- ��y, � �� v� _ =��- � � � � ��