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P - 75036x�,t:"•i"i'ryt�'+'�'W�..,,47 "'2a . ,�xc�,a,s.-..%a�s.�.^•- � CITY OF FRIDLEY WATER AND SEWER CONNECTION PERMIT APPUCATION ;�'LLl �U � �-,� � (Homs ONmerp► PIuR�b�r) Job Address: LEGAL DESCRIPTION S i� �c.� �/ Date: � 19LL�, PERMIT: � � f, SE WE R: WATE R: METE R: FEE: FEE: DEPOSIT: O-DAPTER: STATE _� STATE _� SURCHARGE: SURCHARGE: /� TOTAL:�-�`! TOTAL: /J ' S v TOTAL: �D.U� GRAND TOTAL: �/�� �� S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: NEW STRUCTURE: B�UILDING PERMIT No.: SEWER/WATj�,R P�i, IT 10.: 9�ay SPECIAL ASSESSMENTS: Siyned. � ol� _ By: - �.�.d