P - 43647Engineering WATER AND SEWER Permit No.:
,,7�3-"�72-3552 PERMIT APPLICATION Received ,y,.. � ��
763-571-1287 fax CITY OF FRIDLEY D��c;�������
EFFECTIVE 7/1/2010
APPLICATION DATE: � t` 2 l� 1� YOUR E-MAIL/FAX: _
THIS APPLICANT IS: ❑ OWNER �NTRACTOR
JOB ADDRESS: �O�D �7 � i�. � �
NEW CONSTRUCTION PERMIT� (IF APPLICABLE):
PROPERTY N,q�,�: `p��
TEN�T ADDRESS: �p aZC� " A%�`" f}u C N. C r CITY %= 12 1-S� L�� STATE�ZIP
PHONE: �o ( 2 r- �-j 1 � ^ $'S3�
CONTRACTOR Na�t�: �j'J E� ���-.� E�2 �(.vo4 i� e2.
SUBMIT A COPY OF �DRESS: _SZ70 �%� / c� /1 �-e�" "1�f`�n � CITY � c�,r er ► l� STATPf�/LIP�
YOUR STATE --�
LICENSE WITH PHONE �% !o3—S� 3S'�' 2� 03 CELL PHONE: �! Z-- iia�$ ^�o / Z/
APPLICATION
STATE LIC # STATE BOND: EXP DATE:
1. Narrative/written descri tion:
� _ �.,Y .z-.�.� Y'�..
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations: . � CJ�-�vLJ-.
�
2 e /`-, . . �
3. C�.,� �.-�-�:� -4� b � �
763 -� z- 3ss a. �� �.ep��a� c,o �l��spM-�
PERMIT TYPE
❑ SEWER CONNECTION PERMIT $50
❑ WATER CONNECTION PERMIT $50
❑ WATER LINE REPAIR $40
� SEWER LINE REPAIR $40 D� 0�
❑ ADD STATE SURCHARGE $5.0o S- 0�
❑ SAC CHARGE @ $2100 =
TOTAL $ ��,�'"
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 SHUT-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 (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 perm' d work is not to start without a permit.
SIGNATURE OF APPLICANT T NAME: ��� �J% [1N� DA1'E: %^ Z I^�_
APPROVED BY: __._._ _ DATE: �` C.� .�/D
COPY GIVEN �• U Y BI G(only if new meter) ❑ PUBLIC WORKS ❑ ENGINEERING
c:ity ot r�riciley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-128?
C�
1�
!I
��
����n� �o�
0
��
� o1.e-
w }
. °
l,
Z�
f �
1
�
�
1 1 r'
I5 � �.�� �
�__
��� �
��
_ -� �
� � ��
� o�v
N
�
��� �- �
�
' 1-�,��D �
�-�- �, �,, �-�