P - 35332E:'j;ir���ring WATER AND SEWER Permit No.: 0 a'
76�-572-3552 PERMIT APPLICATION Received By:�_
763-571-1287 fax CITY OF FRIDLEY Date���l:; p��a'�% � Q G�
EFFECTIVE 10/27/2010
APPLICATION DATE �� `� D��� YOUR E-MAIL/FAX:
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THIS APPLICANT IS7: ❑ OWNER '� CONTRACTOR
JOB ADDRESS _/ S�� �I I r� �1 f0�� � j c� 1� _____
NEW CONSTRUCTION PERMIT# (IF APP(�ICABLE):
PROPERTY NAME C.. Ur►./L � Y S�2 r n.
OWNER/ ADDRESS: % �CITY � ,r�s � �Y �/ STATFfhti ZIP
TENANT
PHONE (F �� - �60 � 6% �' �j S""'
CONTRACTOR NAME:�`S /y1 �'Ch � n. � C' xi C i�C
SUBMIT A COPY OF ADDRESS:�� �''cf'U �f/d Gd f� -r n..
YOUR STATE rt` X�l �-i CITY O G/ STATE/rJlt-ZIP�,�G
LICENSE WITH PHONE �6�"' j� �//_ �-Q�( CELL pHUNE: t�j � " 0'—
APPLICATION STATE LIC � S� d� p
STATE BOND: 3% S� EXP DATE: �� 3%" ��%
L : N rrative/written description:
-cD �; K � r°c.� �°K '1-+ 1 s b I U t' Lv ;�'h �''c d�7� S
2. Please Attach sketch showing curb line, utility line, building, etc. with distances on back p�ge.
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3. Stipulations: i . r.-��+C� � �
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PERMIT TYPE
� SEWER CONNECTION PERM]T � SEWER DISCONNECT PERMIT $50
::I WATER CONNECTION PERMIT ::::; SEWER D(SCONNECT PERMIT $50
:� WATER LINE REPAIR $40
a�"i SEWER LINE REPAIR $40
I ADD STATE SURCHARGE $5.00 for each permit
u SAC CHARGE @ $2100 =
TOTAL $ �5 `
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING
NEW WATER METER COST- SEE UTILITY B(LL]NG
SPECIAL ASSESSMENTS — SEE FINANCE
WATBR TAP — SEE ENGINEERING
NOTE: WATER METER REPAIR, INSP OR SHUT-OFF / EVENINGS, WEEKENDS & HOLIDAYS $1251HOUR-B[LLED
THIS IS AN APPLICATION FOR A PCRMIT-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 aperm' nd work is n t t st without a permit.
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SIGNATURE OF APPLICANT PRINT NAME: _� V.�1 SfZ�i% DATE: �� .�U- ��
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APPROVED BY: % DATE: _l L-�U ^ I C,�
C4PY GI TO ❑ UTILI Y BILLINC (only if new meter) � PUBLIC WORKS — ENGINEERING
(:ity of r'ridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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