P - 35337Engineering WATER AND SEWER Permit No.: 0 2�
763-572-3552 PERMIT APPLICATION Received By:,/��
763-�?i'� 1287 fax CITY OF FRIDLEY Date *��1: ���,`�'+�� � Q�L �
EFFECTIVE 10/27/2010
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APPLICA`I'ION DATE: �� `3 � � � YOUR E-MAIL/FAX: —
THiS APPLICANT fS: � OWNER '� CONTRACTOR
JOB ADDRESS �O � 7 � I � �° �/ j� J' �''� I � � � `�
NEW CONSTRUCTION PERMITN QF APPLICABLE): �
PROPERTY NAME: C.. UC, r n-
OWNER/ ppDRESS:�,[�� CITY �lZi,J IY�STATEjh�LZIP
TENANT pHONE: (P �� - �6Q � K ��7 S
CONTRACTOR NAME: /`1 _� �1 Y�%/ ,t� r. + C� Jd L T NC
SUBMITACOPYOF ADDRESS:��'�'� /�%d Ld"'�l1 �.� XSI �,�i CITY �I�JCd '�'/� �e N STATE/yln-ZIP��G
YOUR STATE
LICENSE WITH PHONE �63 i� �/l- �d�l CELL PHONE: � l�' 7�� �'!Sd' 7
APPLICAT/ON STATE LIC #� 6I %� STATE BOND: 3% � EXP DATE: �d` 3 f r� b
1. . _ N rrative/written description: .
�,pi� ?�t ��t°G.� -�K I"f 1 S' k'J I U C 1.t1 ��% ���}� S
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
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3. Stipulations: ` � r--�-� w � �'
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PERMIT TYPE
❑ SEWER CONNECTION PERMIT �.:.� SEWER DISCONNECT PERMIT $50
;.:) WATER CONNECTION PERMIT �_; SEWER DISCONNECT PERMIT $50
❑ WATER L1NE REPAIR $40
�Q SEWER LINE REPAIR $40 �_
Cl ADD STATE SURCHARGE �5.00 for each permit
U SAC CHARGE @ $2100 =
TOTAL $
�l5 °%
OTHER CNARGES (IF APPLICABLE) PAY TO UTILITY $ILLING
NEW WATER METER COST — SEE UTILITY BILLING
SPECIAL ASSESSMENTS — SEE FINANCE
WATER TAP — SEE ENGINEER[NG
NOTE: WATER METER REPAIR, INSP OR SHUT-OFF / EVENINGS, WEEKENDS & HOLIDAYS $125/HOUR-BILLED
THIS IS AN APPC,(CATION FOR A PERMIT•NOT VALID UNTIL PROCESSED
I hereby apply for a water or sewer (new connection or repair) permit and f 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' nd work is n t sta without a permit,
SIGNATURE OF APPLICANT ` PR[NT NAME: �/i- V.�( S%ZCd%C DATE: �� .�U- / d
APPROVED BY: QATE: � � " �C� � � v
COPY GI ��: ❑ UTILI Y BILLING (only if new meter) �1 PUBLIC WORKS - ENG(NEERING
C;ity oi r�rialey
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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