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P - 75017Name 3 ':u,^w=�`+`€�i,1P."°��ta':�''c�`..�e:1�""TMSS'�'!4,� ,.:�"r�i1;'�r�"`.� T." ?',a�.:'. . .r..>i.?nr�.: CITY OF FRIDLEY WATER AND SEWER CONNECTION PERMIT APPLICATION (Homs LEGAL DESCRIPTION PERI�IAT: SENIER: � FEE: WATER FEE s Date: � � 1 �L� �— METER: DEP061T: O-DAPTER: SURCHA AGE: SURCHARGE: TOTAL: ��`S� TOTAL: �S ' S� TOTAL: `�" �� GRAND TOTAL: /V� l/tJ S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: NEW STRUCTURE: BUILDING PERMIT No.: 8� SEWER/WA�TER P NO.•.�_ S'PECIAL ASSESSME `� Siyned;�� �����'�'� �cQ _. By �/