P - 83510. � _ . _ _
Enginee�ng WATER AND SEWER . Pern�itNo.: ��
?63-572-3552 _ PERMIT APPLICATION Receiv� By: ' s-�;
763-57i-1287 fa.x CITY OF FRIDLEY Da�����R ��;�, �
, EFFECTIVE Ol/1212012
APPLICATION DATE: % 7 �" YOUR E-MAIWFAX:
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR � ��
ros ,a�D�ss: �3'(a � f�'� � r i���
AIEW CONSTRUCTTE)N PERMIT# (IF APPLICABLE):
, PROPERTY N�: �
OWi+tER/ f A . � , �
TEATANT ADDRESS: �// �'" [�,P_, v' i G^+ �ti CITY � STAT"� � ZIP ,, .;
FxorrE• '��► 3 S'7 2.. ��j 2 y g""
CUNTRACTOR NAME: �.j
� �� SUBMIT A COPY OF � � � � � � �
ADDRESS: "� t'C� ' CITY � STA ZIP�..�"��Sd� ,
YOUR'STATE � � � '
LICENSE WlTH PHONE `T �,� Li � �C - � 9 l'L CELL PHONE: � ! ':- - 2 S' n "` �" � �1� . ,'
AP'PLIC,ATION �
STATE LIC # STATE BOND: EXP DA7'E:
l. Will work take place in City ROW? Ye No If es, ROW registration is required — see EA��,
; 2. Pravide written description of prop ose work: �-�c tc, S�^�n � c�e.... �-- �, ,
Cc��r �3 �3� � c r� �
3. Attach plan/sketch showing proposed work with existing curb, utilities, trees, buildings; etc.. �+Stfi�<di�ensia►�ns �
` 4. Circle type of erosion control measures to be installed to prevent disttubed soils frorn eroding: �
Silt Fence Bio-rolls Erosion Blanket Sodding Other:
5. Provide minimum of 2 hr notice for inspection ( 8 am - 4:30 pm} �nd call in the following a�': �?63) S72'= ��;
3552, (�63) 5?2-3556, (763) 238-8058, {763) 572-3562 or (763} 572-3551, or (763} 427'-1212,
�, Refer to "Construction Requirements for Water and Sewer Work" on back of page. ;� ;
; 7. Stipulations:
�,
PERMIT TXPE
0 SEWER CONNECTION PERNIIT D SEWER DISCONNECT PERMIT $50
- 0 WATER CONNECTION PERNIIT � WATER DISCONNECT PERMIT $50 ,
� SEWER LINE REPAIR �WATER LINE REPAIR $4p ��
O ADD STATE SURCHARGE $5.00 for eech permit
❑ SAC CHARGE @ �2363 =
TOTAL �
' OTHER CHARGES (IF APPLICABLE) PAY TO T.t'TiLITY BILLIN `
NEW WAi'ER METER COST — SEE UTILITY BILLING
SPECIAL ASSESSMENTS — SEE FINANCE
WATER TAP — SEE ENGINEERING ., _ ''
NOTE: WATER METER REPAIR, INSP OR SHUT-OFF / EVENINGS, WEEKENDS & HOWDAYS $125/H�UR-B�,t.,�
THIS IS AN APPLICATION FOR A PERMTT-NOT VALID UNTIL PR4GESSED
` I hereby apply for a water or sewer permit and I acknowledge that the information above is complete and ac�uratc; that thc v�ork w�ll b� un
confonnance with the ordinances and codes of the City of Fridley. I understand this is not a peimmit but only an applic� f<� e p�it.a�d ..��?
work is not to start without city proval of this pernnit application, uniess ergency repair is required. �� �
Si4NATURE OF APPLIC P RJT NAME: /` ►"'' ��
R 7i/ ���n� DATE. % � ,e ,
.
. . .. . . . . . � . _ �L
t APPROVED BY: DATE: �� I'� �� -
i{��Y %r T0: 0 UTIL B LING (only if new meter) D PUBLIC WORKS ❑ ENGINEEI�TG
City of Fridley
Engineering Department _ a,
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;`�� 6431 University Avenue NE, Fridley, MN 55432 �
763-572-3552 �
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FAX: 763-571-1287 - � :
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