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P - 75041IWme Job A CITY OF FRIDLEY . WATER AND SEWER CONNECTION PERMIT APPLICATION (Hom� o► Py umbsr) �`"D � C��-H�iS <�S��J LECAL ENeSCRIPTION PERMIT: Date• �� � �S 19�_ � / r SEWER: '� WATER: METER: FEE: �Q� FEE: � �U DEP061T: - Uv O-DAPTER: SU CHA GE: 'S� SURCH RGE: �U /, Tf�TAI: �' S V TOTAL: /� S� TOTAL: �- vv ���� a� GRAND TOTAL: S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: NEW STRUCTURE: BUILDING PERMIT No.: SEWER T6R PERMIT/ ..I:,,,.,� SPECIAL ASSESSMENTS• Siyned: �� �-�// / � B�/: 4