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CITY OF FRIDLEY , �
WATER AND SEWER CONNECTION PERMIT
APPLICATION
LEGAL DESCRIPTION
PE R�M IT:
SEWER: ' � WATER:�_ METER:
FEE: ' GO FEE: �'S• �U DEPO6IT:
O•DAPTER:
STATE � STATE S (�
SURCHARGE: SURCHARGE:
' TOTAL: � TOTAL: �`� ' S� TOTAL:
,° �,�� �v
GRAND TOTAL:
S.A.C. CHARGE ON EXISTING STRUCTURE:
EXISTING STRUCTURE: NEW STRUCTURE:
BUILDING PERMIT No.: �� SEWER R P R NO •
SPECIAL ASSESSMi�NTS: s��, ��'�
gy;�i�iiSa�ri �l�l��.�••
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