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P - 75016CITY OF FRIDLE�f WATER AND SEWER CONNECTION PERMIT APPLICATION � Name: %�D l(.�l ti/.1 �Gl � f-.b Date: ��' 19� / t� r PI /�S /(` /C-�SQ�C.� �Ql�! /�./ - Job Address: LEGAL DESCRIPTION PERMIT: sEinreR: '� FEE: `�„ ' `�'� BLOCK TR CT OR ADDITION / /S ��5�� S/ ,•-�- ,�„____ WATER:�_,1 METER: FEE: /S , �v DEP061T: �p. oU O-DAPTER: STATE � � """ .,, S� STATE � SURCHARGE: � SURCHARGE: TOTAI: �"'"� TOTAL:IS ' S� TOTAI: �. v� GRAND TOTAL: / D� UU S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: NEW STRUCTURE: BUILDING PERMIT No.: °?� � , SEWER/W ER P T NO.• SPECIAL ASSESSMENTS: Siyned� � "G�'j� �� - gy; !�a