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P - 62708
Engineering 763�57�.-3552 763-571-12$7 �ax AP�LYCAT70NAAT�: W • L-�' I �- THi3.4�PPiICANT IS: � OWNER �r .fOB A,DbRESS: � i �� � !' NEW CaNSi'AUCTION ��iRMIT# (�k AT'PLICAB�.E): O`W�IER/ 'Y`EN,ANT su�rrA ca�Y oF ,,�A,�ss: ' Yvrn� sTA7E �.1'CENSE WIT19' PHON� � Arp,��c4TroN STATE I.YC # WA`TER �NA SEWER Permit �To.: �vtd-(� tou PER�T AP�'T�ICA.�'X�N Recei�ved By: ��' CX'T'Y Uk' �RIDL�'Y ��cr�v$ oxr�zrzo« �� Y'OUIk E-MAIT-JFAX• � •��11- �` �+ � "� � '��I.L PHON�: ,,4T'E�ZIP � � �' � � � �� � _ 20 �� 1, Will work take pla�e in Gity' RO�V? Yes No Ifyes, ROW registration as required � see Engiuxeering. 2. ]�rovide written description of �roposed wor ,���I � t�.�c, v�� h. iGi,.t�V'�- � 3. 4. 5. 6. 7. ,A.ttaeh plan/sketch showing pzoposed vvark witb existing c�tirb, util�t�es, trees, buildings, exc. with diunensions, Cxrcle type 4f erasion contro� measures to be anstalled to pre�vent di�sturbed. soils fram ez�oding: Si1t k'enee Bio-rvlls �rosion Blanket 5oddivag Other: Provide m�imum of 2 hr not�ce for iaspeetion ( 8 am — 430 pm} and ca11 xn the following arder: (763) 572� 3552, (763) 572-3556, (763) 238-805$, (763) 572-3562 ar (763) 572-3551, bt (763) 427-1212, Re�er to "Const�vction Requi�rements for Watez and Sewer Work" an back af page. St�pulations: PERM��' TY'p� Cf SEVI�R CONNECTION pERMIT ❑ S�WER DISCONNEC'� PERMIT S50 l 1 WA7'ER CONNECTiON F��.MIT ❑ WA'T�Tt D�$CONN�CT PF�1�T $50 C7 SEWLR. �INE REPAIR � WATER L�1E R�PA.IR $40 C7 • bQ. ❑ A,pD S'TAT� SiJitCHARCE 55,00 far eac}� permit -Cyb ❑ SA�C CT�ARGE a(,7 �2365 = xoT�, � '-��.� OT�R C�tGES {IF ,AFPY.IC.ABL�) PAY Td�UT�LITY B�LLING 1�'W WATER MET�R GQST — S�E UT�.Ti'Y BIiLING SPECIAL ASSBSSNt�?NTS � SEF"s F�1ANC� 'WATER TA�.' ^ S�E �Nt�rNEEER�i(3 .nr�n 1�RTMOiS ticnATD rwTCl�nv ev7PT..(lRF!l�VFhiTN�Q WFFKRNL]S�xl(]i.TDAYSI �1i��0�-�II.�.."� _ 7i�IS IS �AlY APPLICATYON FOR A PERM11'-N'O'f VALID UNTII. P�tOCESSED I�ereby apply for a water or sewer peru�it and I aclaw�wledge that ttae infottnat�an above is eomplete and acc�ate; that th� H►ork will lae in conformance vvith the ordiaances and codes of the City of F�idley. I uu�derstand this is not a petmit but only an applicatxon for a pexmit and work is aat to start wiithout ' pp 10£ this pexinit application, uialess emer�ay repair is rec�uoired. st�xa�x�a or• �Pt,zcarrr �.n�rr tve�: ��•�L�i L2 �i � � � ►'� n�.xE: � . � . ( Z i 7 ..._.. A�PROVED AY': -° DP,,'x'�: Z< I� , �Q�3� fslvE TQ: ❑[ITiLIT'Y �ILLTNG ouly if new� mcter) ❑ pU�LIC'WORKS ❑ ENC��ERING _ � �d a�os �aN City of �'rid�ey �ngineering Depart�ent 6431 Univezsity Avenue N�, Fridley, MN 55432 763-572-3552 FA�: 763-571-12H7 1d�IN�N�3W �Mb'HAdf WdZti�$ ziaz 'LZ '�db ` � f � � � �� .. ;� ; a' � � � � � A � .y +� . � $ �g �� � ' � �Y �a ; �x � �i P� � 4 4 Yi � � I � I � �.. . _ .......... ..n,..,......�, . . .i.......��. . .......,.,.... . . .,..,......... ., .,�..,.,.., „_ ........... . .....: � w i !" � � I �I Y L1� � x Uv 3Y I �� , �. ; j �� �- � k� ; � e� u i I � c. 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