P - 84224Engineering WATER AND SEWER Permit No.:r �r 1�--�
763-572-3552 PERMIT APPLICATION Received By: -r�1.�
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763-571-1287 fax CITY OF FRIDLEY Date �e���: �' ' � �� � � � � e
EFFECTIVE O1/12/2012
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APPLICATION DATE: L�� � YOUR E-MAIL/FAX: ^ v%✓'�
THIS APPLICANT IS: ❑ O/W'NER �ONTRACT
JOB ADDRESS: /(,� y]� ����%� ���
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NpME: J '
OWNER/ ,�DRESS: " � CITY �� � STATE l� IP
TENANT
PHONE: " /
CONTRACTOR N,�tE: � ' 3� ,�
SUBMITA COPYOF �DRESS: � CITY STATE �GIP��
YOUR STATE '
LICENSE WITH PHONE � CELL PHONE: � f� �� �'— ��
APPLICATION
STATE LIC # STATE BOND: EXP DATE:
---�.,
1. Will work take place in City ROW? Yes ` o f 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 prevent disturbed soils from eroding:
Silt Fence Bio-rolls Erosion Blanket Sodding Other:
5. Provide minimum of 2 hr notice for inspection ( 8 am — 4:30 pm) and call in the following order: (763) 572-
3552, (763) 572-3556, (763) 238-8058, (763) 572-3562 or (763) 572-3551, 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 ❑ W,,,ATER DISCONNECT PERMIT $50
❑ SEWER LINE REPAIR ,.�WATER LINE REPAIR $40 �
❑ ADD STATE SURCHARGE �5.00 for each permit ��
❑ SAC CHARGE @ $2365 =
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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, wEExErrDS & HoLiDnYS ) $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 city approv t' per it application, unless eme � ency epair is required.
SIGNATURE OF APPLICANT � r,�? PRINT NAME: � �' ! DATE: G>'��% /O�
APPROVED BY: / / DATE: � `.S �� � Z""
COPY GIV�N TO: ❑ vTiLiT BILLING (only if new meter) ❑ PUBLIC WORKS ❑ ENGINEERING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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