P - 75024CITY OF FRIDLEY ��
WATER AND SEWER CONNECTION PERMIT
APPLICATION
Name: V a 1 t e �% u K1 �1 f N Date: M a 1� 1 g R 7
(Hom� Own�r or lumbsr)
Job Address: 6�'f' � y C:�r��5+i4`150h �. qN�
LEGAL DESCRIPTION
PERMIT:
SEWER: -�! ) WATER: / _�-"-1 - METER:�
FEE: Ol/ FEE. ��^�v DEP061T. �
O-DAPTER: -
STATE STATE
� SURCHARGE: SURCHARGE:
TOTAI: TOTAL: TOTAL:
�j G (�
GRAND TOTAL: J � l
S.A.C. CHARGE ON EXISTING STRUCTURE:
EXI�TING STRUCTURE: NEW STRUCTURE:
BUILDING PERMIT No.: SEWER/WATER PER o.: 9 g 9
SPECIAL ASSESSMENTS: Siyned: �
8�/:
r�