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P - 75013� ,; . CITY OF FRIDLEY � " WATER AND SEWER CONNECTION PERMIT APPLICATION � Nsme: (Homs Job LEGAL DESCRIPTION � �SU� � �0� � Date: /—/S 199� PERMIT: SEWER: �' WATER: � METER: � FEE: �S �� FEE: �S U v pEP061T: 0-OAPTER: { STATE � STATE t,� SURCHARGE: SURCHARGE: TOTAL:`�""'"� TOTAL: ��sv TOTAL: GRAND TOTAL: / / U� S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: NEW STRUCTURE: � BUILDING PERMIT No.: SEWER/WA ER PER 0.:�_ SPECUL ASSESSMENTS• S;qned: e�*�r��i-�v c gy; �4 �.G� �!�-�iv