P - 48264�Y�gin�ering WATER AND SEWER Permit No.:�
7�3-572-3552 PERMIT APPLICATION Received By:
CITY OF FRIDLEY
763 -5 71-1287 fax EFFECTIVE Ol/Ol/2011 Date��: � 0�/ 2 ��
APPLICAT'ION DATE: �� /�° f/ YOUR E-MAIL/F'AX:
THIS APPLICANT IS: /� OWNER ,�CONTRACTOR ,/
JOB ADDRESS: L(/ ZD S �� �S�J� r/ �-C�1'� =
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME:
OWNER/ ADDRESS: CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR NAME: S.P.c.Wt �%
SUBMIT A COPY OF .�
YOUR STATE ADDRESS: �'7? ) � Ct�—�- /�� CITY,�,tL1"11_ STAT � ZIP S7� ��U
LICENSE WITH PHONE`�� � �%� t0 i �'�— CELL PHONE: F�/ 2� 2 5 0"��' -�
APPLICATION
STATE LIC # STATE BOND: EXP DATE:
1. Narrative/w 'tten desc ' tion:
. � � ° � S.2/ur�-�---
��� / Q ,�_ //�1 �1% .
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations: 1 � Q �i�"`-�-�V . �-� ` r
76 Z 34s SU Sg DAN �-'�o �J
S7Z 3 °5S6 !�N .
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� PERMIT TYPE
❑ SEWER CONNECTION PERMTT ❑ SEWER DISCONNECT PERMIT $50
❑ WATER CONNECTION PERMIT ❑ WATER DISCONNECT PERMIT $50
❑ WATER LINE REPAIR $40 O
C7 SEWER LINE REPAIR $40
❑ ADD STATE SURCHARGE $5.00 for each permit �
❑ SAC CHARGE @ $2230 = �
� �i
TOTAL $ .�
OTHER CHARGES (IF APPLICABLE) PAY TO 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 IS 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 an ork is not to start ithout a permit.
SIGNATURE OF APPLICA PRINT NAME: �i� DATE: �r �� ��
APPROVED BY: DATE: L � � [
COPY GIV �: ❑ U ILITY BILLING (only if new meter) ❑ PUBLIC WORKS C ENGINEERING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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