P - 48289Enginee`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
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