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P - 48288Enginee`ring WATER AND SEWER Permit No.: �� �OQ 763-572-3552 PERMIT APPLICATION Recei 763-571-1287 fax CITY OF FRIDLEY Date e�. �,, � EFFEC'TIVE O]/01/2011 APPLICATION DATE: S�/ � YOUR E-MAIL/FAX: THIS APPLICANT IS: ❑ OWNER l�ONTRACTOR JOB ADDRESS: � % Z- f� ,� dr> �-� s '7� � � �-- NEW CONSTRUCTION PERMIT# (IF APPLICABLE): PROPERTY NAME: n�'1 -P v S OWNER/ ADDRESS: �, 'Z_Z J �j � C. S i J\I `�-_ CITY STATE ZIP TENANT PHONE: CONTRACTOR NAME: 5�..,� y-k�V SUBMITACOPYOF ADDRESS: `�7 'T1S�.-�— f,Zl CITY � P�- STAT � ZIP SS3�/Q YOUR STATE r LICENSE WITH PHONE ��(.z 3�/"J L ro 7/ L CELL PHONE: _�e / 2� Z c� v��� S� APPLICATION STATE LIC #! STATE BOND: EXP DATE: l. Narrative/written �d scnption�, � (�� /� � v- � .¢-�L � � � �� �— � 7�✓�P � b'�- S , � � 2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page. 3. Stipulations: �`a �- �'�� �4 J' �0 iM ; Q C f� 0 v� Iv► �-� 04�.5 t�v� b a C� d� �` I�� �' q �� Z h�s t�1`;,01' t� +�Sp2�%io� p �o��r��.. c.,/ DS�� S�,°�ef�- q�i`���:� PERMIT TYPE ❑ SEWER CONNECTION PERMIT ❑ SEWER DISCONNECT PERMIT $50 � WATER CONNECTION PERMIT � WATER DISGONNECT PERMIT $50 ❑ WATER LINE REPAIR $40 D ❑ SEWER LINE REPAIR $40 ❑ ADD STATE SURCHARGE $5.00 for each permit 0 � SAC CHARGE @ $2230 = TOTAL $ " �� v 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 REPAIIt, INSP OR SHiJT-OFF / EVEMNGS, WEEKENDS & HOLIDAYS $125/HOUR-BILLED THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED I hereby app(y for a water or sewer (new connection or repair) permit and I acknowledge that the informarion above is complete and accura.te; that the work will be in conformance with the ordinances and codes of the City of Fridley. 1 understand this is not a permit but only an application for a permit d work is not to start without a permit. _ SIGNATURE OF APPLICA � ` �I �4M pRINT NAM�N�i ��� DATE: / � '^! / / � APPROVED BY: �� DATE: � I I COPY GIVEN TO: �Cl UTILITY BILLIN (only if new meter) ❑ PUBLIC WORKS C ENGINEERING City of Fridley Engineering Department 6431 University Avenue NE, Fridley, MN 55432 763-572-3552 FAX: 763-571-1287 ���