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P - 35493Engineering WATER AND SEWER Permit No.: 763 �572-3552 PERMIT APPLICATION Received By: � 76�-571-1287 fax CITY OF FRIDLEY D����1AR 1� 20 1 4 EFFECTTV E O l/O l/2011 APPLICATION DATE: ��,Q`� � YOUR E-MAIL/FAX: _ THIS APPLICANT IS: ❑ OWNER �CONTRACTOR f JOB ADDRESS: �S1�CPJ'� ' GV��/'C. W `�— NEW CONSTRUCTION PERMIT# (IF APPLICABLE): � PROPERTY NAME: i� e C OWNER/ ADDRESS: /�� �, CO✓�C�7 Cu� CITY � STATE ZIP . TENANT rHONE: `l� `t � CONTRACTOR NAME: — p.J • SUBMITA COPYOF ADDRESS: ��SS O c���-` 7 YOUR STATE �CITY Y!^o� S7'AT �ZIP LICENSE WlTH PHONE ��?3 5����I�J� CELL PHONE: %�� CF" 0�9 APPLICATIDN STATE LIC # STATE BOND: EXP DATE: 1. Narrative/ itten description• � , ,� y" � �' �re��:., yl� �c� a ., i� ` ,, � 2. Please attach sketch sh wing curb line, utility line, building, etc. with distances on back page. 3. Stipulations: �PV'Y1 C D CDV►Y1P Ci't��+n S W% S'i�i� �l ��55 6ct��5 . Cal` �01' ir�S ee���uv� J����' f0 6gC��l . �►52 J`o 2s 6,n,� rf;�cvti vtieE�odS.� A��Pfe -FD OSt,Q S«`�r+y Sfav►aa.rc�s. ��� ��a,�-�� ° PERMIT TYPE ❑ SEWER CONNECTION PERMIT ❑ SEWER DISCONNECT PERMIT $50 ❑ WATER CONNECTION PERMIT C; SEWER DISCONNECT PERMIT _$50 ❑ WATER LINE REPAIR $40 �� SEWER LINE REPAIR $40 ❑ ADD STATE SURCHARGE $5.00 for each permit ' 0 SAC CHARGE @ $2230 = �� U . TOTAL $ `�� ' OTHER CHARGES (IF APPLICABLEj PAY TO UTILITY BILLING NEW WATER METER COST — SEE UTILITY BILLING SPECIAL ASSESSMENTS — SEE FINANCE WATER TAP — SEE ENGINEERING NOTE: WATER METER REPAIR, INSP OR SHLTT-OFF / EVENINGS, WEEKENDS & HOUDAYS $725/HOUR-BILLED THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED I hereby apply for a water or sewer (new connection or repair) permit and I acknowledge that the information above is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Fridley. I understand this is not a permit but only an application for a permit is n t start without a permit. SIGNATURE OF APPLICANT '�'�_ PRINT NAME: �I �� _ DATE: S 1(0—1 � APPROVED BY: DATE: COPY G EN TO: ❑ ILITY BILLING (only if new meter) � PUBLIC WORKS ,_� ENGINEERING City of Fridley Engineering Department 6431 University Avenue NE, Fridley, MN 55432 763-572-3552 FAX: 763-571-1287 I, + i ` � / ♦� o J 5 � � n < � � h�' l \ �<, � d� � � g � � � � � � � C° �� #�� � �. F � � �, � � � ��o � �' a � = �c � � � �.. \ \ \ � � d� � ��, � �X � ------�� � � � C� � � � � � � ^� � � e, �