P - 45728Engineering WATER AND SEWER Permit No.• ]�-p��l.�
763-572-3552 PERMIT APPLICATION Re eiued B�Y�;�--�—
763-571-1287 fax CITY OF FRIDLEY Da�!��'������ ���
EFFECTIVE Ol/Ol/20] 1
APPLICATION DATE: �� �-'� / YOUR E-MAIL/FAX:
THIS APPLICANT IS: ❑ OWNER ❑ CONTRACTOR �j � /
JOB ADDRESS: ��� � �/'7.@ � f�-- " /�f � �--�
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME: r r � r
OWNER/ pDDRESS: CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR NAMg:
SUBMITA COPYOF ADDRESS: �-t, I�Z CITY STAT ZIP�+�2
YOUR STATE � '� � � �
LICENSE WITN PHONE�,(� �.- �%� (t� '� I�-- CELL PHONE: 6� 2� 2 g O^� 3`T ��
APPLICATION
STATE LIC # STATE BOND: EXP DATE:
1. Narrative/wr' en description: � `"'
Lt.�%� 1.��. C�c�. !.0 � ��- •. ����J�-SC�-�
�
2. Please attach sketch sho ' curb line, utility line, building, etc. with distances on back page.
3. Stipulations: �� ,C.�.�IJ' � C.. �/�Q
� �o` n � z ` c.�,�f--� e
` ` � �.j 'Z e-NL S �,,� • �b 3 57z 3 S � Z
� 3ss�
PERMIT TYPE Z 3$ ^$U SS
$�`f8
0 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 =
L�' �
TOTAL S � —'
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, 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
accura.te; that the work will be in conformance with the ordinances and codes of the City of Fridley. 1 understand this is not a permit but
only an application for a permit work is not to start without a permit.
SIGNANRE OF APPLICANT � P -- O Z�
APPROVED BY: DATE: �� G-O ��
COPY G N :❑ U iTY LLING (only if new meter) ❑ P IC S C ENGINEERIN
City of Fridley
Engineering llepartment
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
�ol ,
� �
� �
�
O
0
�
\9
�
�
�
�
5
�
�
d.
W
s
3
`--7
k
0
�
�
' c—�--�
�
�
�
�
s
�
�
�