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P - 75018� CITY OF FRIDLEY � � �: WATER AND SEWER CONNECTION PERMiT � APPUCATION �/�//��/��,�� =�� Date• -3�� 19 � ! � (Home Ownsr or Plurr�r) dreas: / 33 �'i f�i�� 'j �:4 ..- �U.t C� L� /O � �K , ri� AC /O�- �D� DESCRIPTION ,� � �T: ✓,, �"/la 55: �� _ ,i SEWER: WATER: METEii: FEE: FEE: DEPQSIT: � O-DAPTEii: STATE STATE SURCHARGEc SURCHARGE: TOTAL: 5' s TOTAL: �S ' S� TOTAL: � GRAND TOTAL: ID� UU 4.C. CHARGE ON EXISTING STRUCTURE: �XISTING STRUCTURE: NEW STRUCTURE: '� / �'� UILDING PERMIT No.: �� g� SEWER/W F�p T NO.�[� CIAL ASSESSMENTS: '" S'iyned: ✓ Aa��'4 I�''�l7'fJt� �: gy v �