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P - 75043��'�a*���:�F'�-'yi;�rF`,�u��;� � .�`;`�. r=m'�-.��m �'�.. ' CITY OF FRIDLEY WATER AND SEWER C'ONNECTIOFV PERM{T '� APPLICATION Name: (Horm OwrNr or Plumb�r) .lob Addr • �'%�v/ 3 � LOT NO. BLOCK LEGAL DESCRIPTION �Gt � �� ,� � .,: � -g:�::_ Date: �d � �S 19�_ � PERMIT: SEWER: �r WATER: ✓ METER: FEE: s� FEE: S. UU OEPOSIT: � GJ (p 0� UZI O-OAPTER: STATE � STATE s� SURCHARGE: SURCHARGE: TOTAL: �« , S J TOTAL: ��• S O TOTAL: °� y O�� GRAND TOTAL: ���"� T' � g � � � S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: NEW STRUCTURE: { ' BUILDING PERMIT No.: �� S�3� SEWER/W fR PERMIT 9�.: �9 SPECIAL ASSESSMENTS: Sipned• ��u'� t�`�� (o BY��