P - 35339Engineering WATERANDSEWER PermitNo.: lSO i
76�-57�-3552 • PERMIT APPLICATION Received By: �����
76�� 571-128�}fax CITY OF FRIDLEY Date�e�'Qt: N�U 20
EFFECTIVE 7!1/2010
APPLICATION DATE: � ��� �� YOUR E-MAIUFAX: _
THIS APPLICANT IS: O OWNER �'CONTRACTOR
JOB ADDRESS: S\4' =J O���,"�4i 1�,� �-T
NEW CONSTRUCTION PERMIT� (IF APPLICABLE):
PROPERTY NpME: !'; c>.�v i'� S�a �6 cr
OWNER/ ,qDDRESS: ��O / nn� ka s'T N� CITY �� STATE�ZIP
TENANT pHONE: �D�Z - ��3 Y
CONTRACTOR J�pMg: �` � ' vr�, �n
SUBMITA COPYOF �DRESS: �% CITY S STATE�ZIP SSy33
YOUR STATE
LICENSE WITH PHONE ln /Z %�% lnl/Y CELL PHONE:
APPLICATION STATE LIC �! S�E� � P/� l STATE BOND: / /O �/ON EXP DATE: 1 Z 3/ 2v/
1. Narrative/written descri tion: � �
�� i
e�.�cv fti,par'r P �.�r� -�-,_� �,c� ldC� S�`��� e ��"> y, �d �C.4�,oc�+�
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations:
_,... ..�
PERMIT TYPE
,
( ,�SEWER CONNECTION PERMIT $50
�� O WATER CONNECTION PERMIT $50
❑ WATER LINE REPAIR $40
� SEWER LINE REPAIR $40 !, "'
0 ADD STATE SURCHARGE $5.0o S. °°
O SAC CHARGE � @ $2100 = �%S � °
TOTAL S
OTHER CHARGES (IF APPLICABLE) PAY TQ UTILITY BILLING
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 tS AN APPLICATION FOR A PERMIT-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 a permit and work is not to start without a permit.
SIGNATURE OF RPPLIC T �'`�'``- ` PRINT NAME: /� ��''� / os'�� �t DATE: �� �1 ��
APPROVED BY: ='' ., DATE: L� I� I�
COPY GI T: o LITY BILLING (only if new meter) ❑ PUBLIC WORKS ❑ ENGIIV ERING
(".itv nf Fridlev
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
650� rANOKA ST , FRIDLEY MN .
SEWER REPAIR