P - 84386Engineering WATER AND SEWER Permit No.: t� d. ��
763-572-3552 PERMIT APPLICATION Received By:
763=571-'1287 fax CITY OF FRIDLEY Date �1 (�,,�';�' �. $ Z�
EFFECTIVE Ol/12/2012 �� . ,a
APPLICATION DATE: � n"- I iS - I Z- YOUR E-MAIL/FAX: _
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
JOB ADDRESS: �� R(� A L-1� E�V i.�/A�.. nl• C.
NEW CONSTRUCTION PERMIT# (IF APPLIC,4BLE):
PROPERTY NAME: I�(L�S19' �}�AD�-t'Y
OWNER/ p�DRESS: '/g��o Ai-DL/1/ 1.i.�,A�1 �ITY STATE ZIP
TENANT
PHONE:
CONTRACTOR NAME: ���5 S�Gv �Z- 't' (ti�4 �'iC--.
SUBMITA COPYOF �DRESS: 1/k �'�'-1 /�x,3�7 N: 1= . CITY
YOUR STATE /�ti�t-t-'r4' u STATE�ZIP 33--313
LICENSE WITH PHONE `�4y� ,S 3.S =„3�U3 CELL PHONE: !'v/Z �hFs`� lv�L/
APPLICATIDN
STATE LIC # STATE BOND: EXP DATE:
1. Will work take place in City ROW? Yes��If yes, ROW registration is required — see Engineering.
2. Provide written description of proposed work:
3. Attach plan/sketch showing proposed work with existing curb, utilities, trees, buildings, etc. with dimensions
4. Circle type of erosion control measures to be installed to pre bed soils from eroding:
Silt Fence Bio-rolls Erosion Blanket So in Other:
5. Provide minimum of 2 hr notice for inspection ( 8 am — 4:3 pm) and call in the following order: (763) 572-
3552, (763) 572-35a�`1 (763) 238-8�'�, (763) 572-3562 or (763) 572-35�p�or (763) 427-1212.
6. Refer to "Construction Requirements for Water and Sewer Work" on back of page.
7. Stipulations:
PERMIT TYPE
� SEWER CONNECTION PERMIT ❑ SEWER DISCONNECT PERMIT $50
❑ WATER CONNECTION PERMIT ❑ WATER DISCONNECT PERMIT $50
❑ SEWER LINE REPAIR �( WATER LINE REPAIR $40 ,�
0 ADD STATE SURCHARGE $5.00 for each permit
❑ SAC CHARGE @ $2365 =
TOTAL $ --�
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLIN
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 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 permit and
work is not to start without c' a roval is permit application, unless emergency repair is required.
SIGNATURE OF APPLICAN PRINT NAME: ���� i%� !/�/✓ DATE: � O"��-/Z
APPROVED BY: DATE: PU ��G' � Z,.
COPY GIVEN TO: T Y BILLING (only if new meter) � PUBLIC WORKS ❑ ENGIN ERING
City of Fridley
F,n�ineerin¢ nenartment
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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