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P - 75065
�'"",k-'l�.TW'!'�'. ...� S.+§ .:;µ+i; pT'�r t� � c . •" y,;_G'�- .r,t� �° : a;'R,z, ✓�•Y�r•;r: � r;;t r ,,.�r . . �:�a� CITY OF FRIDLEY � : WATER AND SEWER CONNECTIQN PERMIT AtPPLICATION �: (Nom� Own� or Plumb�r) ,Job es�: - `���= r �'�y'7, 4 :,� .LEt�A1� DEfiCAIPTiON - 4 � �' � . PE1t�AIT: Date: °?—�� �ti��� �WER: �r WATER: '"'�� METER: FEE: �� FEE:� pEP061T: O•DAPTER: STATE �"-Q STATE �"�U SURCHARGE: SURCHARGE: TOTAL: � TOTAL: ��� TOTAL: �',y� vv GRAND TOTAL: S.A.C. CHARGE ON EXISTING STRUCTURE: EXtSI'ING STRUCTURE:i BUILDING PERMIT Na� SP�CIAL ASSESS�IENTS: F i �� NEW STRUCTURE: � "'� SEWER/W�E� NO.: � S� _ ey: i�-�