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P - 75053. .. . . . .a. t .�,t �.: , ;r-. f . >�� ic� . 7 � CiTY OF FRIDLEY WATER APID SEWER CONNECTION PERMIT APPLICATION Nm»: Ul4��e y �u•s� b. = -� . (Hom� OwMr or .��: � ya �,�,� LEGA�;.,Q�:IRIPTION �r'. � .� PERMIT: ' li�� / :. Date: � �6 �S� 19 �.s�z c�- SEYVER: � WATER: ( METER: � �j FEE: 'as - FEE: �� DEP061T: v� 0•DAPTER: SURCHA GE: 's� SURCH RGE: � � � TOTA��S� TOTAI:� ' S b TOTAL: u"" / . GRAND TOTAL: /�/ � S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: NEW STRUCTURE: BUILDING PERMIT No.: � SEWER/WAT P IT O.: r SPECIAL ASSESSIYIENTS: - Siqned: v ey: .J