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P - 75050
. �,:.1�'#�X ... . :;il � *,�:.: � ;r+�m.� x .. ^�=.•'w�kt:'�." .�l:�;�^�r�z+:....: �:tr w�w+�:a ::�z : . . . . .. /, . �� . . . . � . L � CITY OF FRIDLEY WATER AND SEWER CONNECTION PERMIT � APPLICATION IHom� O e� or Plumb��) Job Addresa: ��� !o �� r �� � LOT NO. � LEGAL DESCRIPTION / PERMIT: . / SEYVER: FEE: �'S � Date: %� - � 1� . .�— _ _ _.__— WATER: METER: _��` FEE: �S'� OEP061T: �U•CX� O-�APTER: STA� Sd BTATE �(j SURCHAR E: SURCHARGE: TOTAL: � ' �� TOTAL: S ' `i � TOTAI: �Sd,1. GRAND TOTAL: � /� � O� S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: �, NEW STRUCTURE: BUIIDING PERMIT Nd.: � SEWER/W+!►�R PERMIT SPECIAL ASSESSMENTS: Sgr�d. r�� �m � .�- BY: � �,�