P - 35442Engineering
"',�3-572-3552
763-571-1287 fax
APPLICATION DATE:
THIS APPLICANT IS:
JOB ADDRESS: �
NEW CONSTRUCTION P
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
1.
❑ OWNER
(IF APPLICABLE):
rc. 1 n
ADDRESS:��
PHONE ���i''c�'
STATE LIC #�
ten description:
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WATER AND SEWER
PERMIT APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7/1/2010
,
YOUR E-MAIL/FAX:
:R�CTOR _ ,i ^ nr I G� �,
�
Permit No. ��°� 1� .-�?�,
Received By: '
Date Rec'd: �� � ' � �(�
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2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations:
PERMIT TYPE
❑ SEWER CONNECTION PERMIT
❑ WATER CONNECTION PERMIT
❑ WATER LINE REPAIR
❑ SEWER LINE REPAIR
O ADD STATE SURCHARGE
❑ SAC CHARGE @ $2100 =
$50
$50
$40
$40
$5.00
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 SHLJT-OFF / EVENINGS, WEEKENDS & HOLIDAYS $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LJNTIL 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 rk is art w' out a permit.
SIGNATURE OF APPLICAN � RINT NAME: e DATE: -�"
APPROVED BY: DATE: � L-- ��— I('�
COPY G T�: O LITY 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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