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P - 75046
CITY OF FRIDLEY WATER AND SEWER CONNECTION PERMIT APPLICATION �(�� � � Name: o i � .c�p rn�.j Date• /O - 3i 19� I� (Hom� OvNnr w Plu 1 Job Addreas: �7 � �f �� t.I/��oiv � �C.i� LEGAI DESCRiPTION PERMIT: � (�vSS� ✓ ✓ SENIER: WATER: METER: FEE• °2SUU FEE: /S ,UO pEPOSIT� O-DAPTER: STATE S� STATE s (� SURCHARGE: SURCHARGE: TOTAI: " - " -- TOTAL: /� S � TOTAL: �' QU GRAND TOTAL: /v� U� S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: NEW STRUCTURE: BUILDING PERMIT No.: -�/ �� SEWER/W./��T�E ER NO.: � SPECIAL ASSESSIIAENTS: Siyn�d. l�d'-G`'� By: , .