P - 48069Engineering WATER AND SEWER Pern,it No.: p�,-r�'�I Stp
763-572-3552 PERMIT APPLICATION Received By:l��J
763-571-1287 fax CITY OF FRIDLEY ���.
EFFECTIVE O1/O1/2011 �
APPLICATION DATE: f"'��/ 2..�� YOUR E-MAIL/FAX: _
THIS APPLICANT IS: ❑ OWNER �CCONTRACTOR / ,,f
JOB ADDRESS: � S(3 p C h,a,�, r P !�- (Z �-%
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME: i c9 a� ✓ — —
OWNER/ ADDRESS: CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR NAME: 4 �
SUBMITA COPYOF qDDRESS: �S"- c� v.�-t � CITY STAT ZI 3 C )
YOUR STATE C..� � � �- ��
LICENSE WlTH PHONE /b �—�1 > F—b �� 2 CELL PHONE: �/2 '`Z-5 0^- � 3% S'—
APPLICATION
STATE LIC # STATE BOND: EXP DATE:
1. Narrative/written description� � A_ S�e�' � �n-� d
a.�:. u� ��.�.L�J� (.cQ.,%i s \ `� ~?�
2. Please attach sketch showing curb line, u�lity line, building, etc. with distances on back page.
3. Stipulations: l. �L�� 2. l�D�
- �,, 3.
2{� ���.9,�,� 0�—� 7� 3 s�z 3 Ss.�
763 Z3g $059
PERMIT TYPE �ER�.�1E --7 763 S�2 3SSZ
❑ SEWER CONNECTION PERMIT ❑ SEWER DISCONNECT PERMIT $50
� WATER CONNECTION PERMIT ❑ WATER DISCONNECT PERMIT $50
❑ WATER LINE REPAIR $40
❑ SEWER LINE REPAIR $40
❑ ADD STATE SURCHARGE $5.00 for each permit
❑ SAC CHARGE @ $2230 =
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 / EVEI�iINGS, 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 e ork is not start ithout a permit.
SIGNATIIRE OF APPLIC�� PRINT NAMEO� C, i�?i �� DATE: � L/?// /
APPROVED BY: DATE: ! Z � Z I
COPY GI N :❑ I TY ILLING (only if new meter) ❑ PUBLIC WORKS C ENGINE RING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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