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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: %