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CITY OF FRID�EY .��li�p
WATER AND SEWER CONNECTION PERMIT �
APPLICATION
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LEGAL DESCRIPTION
PERMIT: /
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� NO. BLOCK T ACT OR
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SEWE R: WATE R: METE R:
FEE: FEE: �EP061T:
O-DAPTER:
SURCHA GE: SURCHARGE:
TOTAL: �'"�-' '�� TOTAL: � C' S� TOTAL: �
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GRAND TOTA�:
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S.A.C. CHARGE ON EXISTING STRUCTURE:
EXISTING STRUCTURE: NEW STRUCTURE:
BUILDING PERMIT No.: SEWER/W T,ER _P/�E MIT NO.: � g
SPECIAL ASSESSMENTS: Siyn : �'�'`�' ��''�''�'—'
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