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P - 75057
� �ws;�;� .:...... .: ....;.�,,,�,�,�.,waA"�^�Yc::�.�"-"^n...ri�-::;���' '" i�.� '"'�?� .. -, CITY OF FRIDLEY WATER AND SEWER CONNECTION PERMIT APPLICATION Y, (Hom� .IOb Address: / oC LEGAC DESCRIPTION PERMIT: Plumb�r) n ,- 1^ �. � � ✓ Date: �' a d 19 �L ) �� SENIER: ✓ WATER: f' METER: �vv � FEE• °��' • w FEE• ��QD OEP061T:�� O-OAPTER: STATE S'b STATE � SURCHARGE: SURCHARGE: TOTAI:��v TOTAL: ��-�U TOTAL:�v �'�p �v GRAND TOTAL: / S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: ^ NEW STRUCTURE: .�■ BUILOING PERMIT No.: �SEWER/W ER PERMIT SPECIAL ASSESSMENTS: Si�ned: Y; � J