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P - 75056
, . . ��.�.�., ..,�. __ _ . . ., , . , • CITY OF FRIDLEY �� WATER ANDSEWER CONNECTION PERMIT APPLICATION Ns�e: � / Date• �'�L� 1�_ .w�:s�r�• (oL�O� �C�� i�T��lS 0 Iv L-�I�� LEGAI�.D�RIPTION - — - - � D � PERMIT: r S�, � SEWER: WATER: METER: L"� FEE: • �v FEE:1�� DEP061T:��L.1 O-DAPTER: STATE �� STATE � SURCHARGE: 8URCHARGE: �� TOTA�:�`— "" - TOTAL: �S' �� TOTAI: c��L1S.1 GRANDTOTAL: ��`-'/ v� S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: NEW STRUCTURE: BUILDING PERMIT No.: SEWER/VyA�ER PERMIT S�ECIAL ASSESSMENTS: Si�ned. V � ' ey: