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P - 74963��3 � � CITY OF FRIDLEY WATER AND SEWER CONNECTION PERMIT APPLICATION Name: S��^' W � �i�;Nv� c�'G`r �'` Date: `� ��`f 19� (Home Owner or Plumber) �, Job Address: � � � � �'`� � K �i � S / IEGAL DESCRIP�ION TRACT OR ADDITION �, (2ic� CR;.� r` ,� A� I ti- PERMIT: c.� ✓ SEWER:�— WATER: METER: FEE: °�� Uv FEE: �� DEP061T: ---, O-DAPTE R: STATE ,� STATE , C.� SURCHARGE:�`_( SURCHARGE: TOTAL: °1O� ' J� TOTAL: /� "' " T AL: ��/ Uo GRAND TOTAL: S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: NEW STRUCTURE: BUILDING PERMIT No.: SEWER T R PF�f,iMll � SPECIAL ASSESSMENTS: Signed: w� . By: