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Cl'TY OF FRIDLEY
WATER AND SEWER CONNECTION PERMIT
APPLICATION
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(Horr» woe� w Plumb�r)
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LOT NO.
IEGAL DESCRIPTION ,� /
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PERMIT: /
SEWER: �-^� WATER: � � METER: v
FEE: FEE: DEP061T:
O-DAPTER:
STATE ,� STATE �
SURCHARGE: SURCHARGE:
TOTAL:�S S� TOTAL: �� S� TOTAL: '�O
i
GRAND TOTAL.: /�� �
S.A.C. CHARGE ON EXISTING STRUCTURE:
EXISTING STRUCTURE: NEW STRUCTURE:
BUILDING PERMIT No.: SEWER/WATER PERM�,�O.: � O
SpECIAL ASSESSMENTS: Siqned: ����`� ��
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