P - 48277Engineering WATER AND SEWER Permit No.:
763-572-3552 PERMIT APPLICATION Received By:
763-571-1287 fax CITY OF FRIDLEY D��'�,�pY 2 �0j
EFFECTI V E 01 /01 /2011
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APPLICATION DATE: � � 2" � ` �( YOUR E-MAIL/FAX: �''�v�- � 'g�cF- �° G ^'' ``{ ` I • C'c'"� _
THIS APPLICANT IS: ❑ OWTdER �CONTRACTOR
JOB ADDRESS: S�d! � / � v ..ib f �q ��c S�' �' �C./ (�
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME: �e ''�'� °"` �� Cm f �
OWNER/ ADDRESS: CITY STATE ZIP
TENANT pHONE: i� � L^ 7�� ��' �3
CONTRACTOR NAME' Nu s�, �] � ..�.� � rz.q.y k r�.- �� +�-� � c n
SUBMIT A COPY OF ADDRESS: I�I L i/ ?j rc.�Q S�i- N� GTY ���s STATEyN �ZIP S�'�S i��
YOUR STATE
LICENSE WITH PHONE CELL PHONE: �e � 2 �6 ? 7^!� 9 r Z � 3/^� f
APPLICATION c�,
STATE LIC # � ( 2' �' � STATE BOND: EXP DATE: �
1. Narrative/written description: • -,�..Tu-tx �.e�.c/�'�-� `'��` t
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2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations: V � � ��
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21 c'�Z- ?j55/ 02 238 � �'Y�C3 ,�J4yNE
.J PERMIT TYPE
❑ SEWER CONNECTION PERMIT ❑ SEWER DISCONNECT PERMIT $50
❑ WATER CONNECTION PERMIT �:; SEWER DISCONNECT PERMIT `$50
❑ WATER L1NE REPAIR $40 �'
� SEWER LINE REPAIR $40 � �
L ADD STATE SURCHARGE $5.00 for each permit
0 SAC CHARGE @ $2230 = _
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. TOTAL $ s � ----_
,OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING
NEW WATER METER COST - SEB UTILITY BILLING
SPECIAL ASSESSMENTS - SEE FINANCE
WATER TAP - SEE ENGINEERING
NOTE: WATER Iv�TER REPAIR, INSP OR SHlJT-OFF % EVENINGS, WEEKENDS & HOLIDAY3 $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LtNTIL PROCESSED
I hereby apply for a water or sewer (new connection or repair) permit and I acknowledge that the information above is camplete 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 d w C is not to start without a permit.
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SIGNATURE OF APPLICANT PRINT NAME`. ��v� ���(G pq�: �— L�
APPROVED BY: DATE: �
COPY GIVE 0: � UTIL Y BILLING (only if new meter) ❑ PUBLIC WORKS i_� ENGI EERI G
I�ILy OI I� flQley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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