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P - 75039�f�T j•,p" � � CITY OF FRIDLEY 1QfATER AND SEWER CONNECTION PERMIT APPLICATION Name: _ �� e� �`� "` h • ' � Date: �� a 19S ! (Hom� OwrNr a Plumb�r) mb Job Address: �� '•�� S'!'.o s°�`'- �'� . LEGAL DESCRIPTION PERMIT: �, , SEWER: � .WATER• FEE• "` � � FEE•!S .OD ./Y.��'� O-OAPTER: � STATE � � STATE S� SURCHARGE: SURCHARGE: TOTAI: `^— `� `� TOTAL: ' — ' — � � �O/ �o GRAND TOTAL: METER: � DEPOSIT: `"`" `� `� TOTAL: � ""'�✓ SA.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: NEW STRUCTURE: BUILDING PERMIT No.: �5 SEWER�%� E ER , `� SPECIAL ASSESSMEN . Si U ?�`�5 lU- �r� � BY' ` , %/�%�O �