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P - 75015CITY OF FRIDLEY WATER AND SEWER CONNECTION PERMIT APPLICATION (Homs Ow r w Plumb�r) Job Addresa: �� / ', ( �NS LEGAI DESCRIPTION �T�o. �C PERMIT: ,. ✓� SEWER: ✓_ WATER: �' FEE: �'"-" `�'� FEE: � ��a � Date: �'�� 1�Z.�. METER: DEP061T: O-DAPTER: STATE � STATE � SURCHARGE: SURCHARGE: TOTAL: ' � � TOTAL: /�f `�� TOTAL: -Lf�00 GRAND TOTAL: 7 .. S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTlNG STRUCTURE: NEW STRUCTURE: BUII,OING PERMIT No.: ` SEWER/WATER PERMIT O.: 9� 83 SPEt'�AL ASSESSMENT • Siqned: � gy; �s--�-�-