P - 75025CITY OF FRIDLEY �
WATER AND SEWER CONNECTION PERMIT
APPLICATION
Nam�e: V� � � u� br`vi y Date: Me �� � g q�
(Nomr or Plumb�r)
.lob Addreas: __I S jf C ti�' i 5�; Gc-1 S Ovi � c' �✓�'
I IOTjNO. I B� K �� TQACT OR ADOITION� n�
LEGAL DESCR IPTION �„� <.�p / C� d �� �\ A 1'/
PERMIT:
SENIER: � WATER: � METER: �
FEE: �'� "`� FEE: � OEP061T: � ��
O-DAPTER:
STATE � STATE S�
SURCHARGE: SURCHARGE:
TOTAL: ` ° '" - TOTAL:L=" TOTAL: �� `''�
GRAND TOTAL: ��D� Gv
S.A.C. CHARGE ON EXISTING STRUCTURE:
EXISTING STRUCTUFIE: NEW STRUCTURE:
BUI�DtNG PERMiT No.: SEWEFi/WAT ERMIT�I .:
SPE�IAL ASSESSMENTS: Siqned: ` �
BY: %