P - 62709Engineering WATER AND SEWER Permit No.: (� �
763-572-3552 PERMIT APPLICATION Received By:F
763-571-1287 fax CITY OF FRIDLEY ���e��7 �" 2��2
EFFECTIVE Ol/12/2012
APPLICATION DATE: � ,� - / ` YOUR E-MAIL/FAX: _
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
JOB ADDRESS: ,�""�� rJ �f s'1 � cF e i^ ,��
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NpME: F r r T' .T E
OWNER/ ADDRESS: ` �/' � CITY �� C"c STATE�IP�J'G�i
TENANT pxotvE: i(v3 - S'7 / - �c3 �O
CONTRACTOR NAME: � G
SUBMITACOPYOF ADDRESS:��i�,>%� �ST /v� CITY �i ,(,�,n��C1�/s STATE`%"%!lZCP SS��a
YOUR STATE �
LICENSE WITH PHONE G�,E�- `U-��' ��% CELL PHONE:
APPLICATION
STATE LIC # C� ..30 "' STATE BOND: EXP DATE:
1. Will work take place in City ROW? Yes �N If yes, ROW registration is required — see Engineering.
2. Provide written description of proposed work:
3. Attach plan/sketch showing proposed work with existing curb, utilities, trees, buildings, etc. with dimensions
4. Circle type of erosion control measures to be installed to prevent disturbed soils from eroding:
Silt Fence Bio-rolls Erosion Blanket Sodding Other:
5. Provide minimum of 2 hr notice for inspection ( 8 am — 4:30 pm) and call in the following order: (763) 572-
3552, (763) 572-3556, (763) 238-8058, (763) 572-3562 or (763) 572-3551, or (763) 427-1212.
6. Refer to "Construction Requirements for Water and Sewer Work" on back o�page.
7. Stipulations: �� � �
PERMIT TYPE
❑ SEWER CONNECTION PERMIT ❑ SEWER DISCONNECT PERMIT $50
❑ WATER CONNECTION PERMIT ❑ WATER DISCONNECT PERMIT $50
❑ SEWER LINE REPAIR `� WATER LINE REPAIR $40 r�0. Q a
❑ ADD STATE SURCHARGE $5.00 for each permit ��"
❑ SAC CHARGE @ $2365 = ,
TOTAL $ '
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING (,��
NEW WATER METER COST - SEE UTILITY BILLING "���"� _l V�
SPECIAL ASSESSMENTS - SEE FINANCE C����
WATER TAP - SEE ENGINEERING �`
NOTE: WATER METER REPAIR, INSP OR SHUT-OFF / EVENINGS WEEKENDS & HOLIDAYS $125/HOUR-BILLED (�
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED �J
I hereby apply for a water or sew r permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinance and codes of the City of Fridley. I understand this is not a permit but only an application for a permit and
work is not to start without city proval of this permit application, unless emergency repair is required.
SIGNATURE OF APPLICANT PRINT NAME: c /I,�\ l�� '+'/l �'✓g DATE: —I ' J' � 2-
� r�° .� . . _ _ ,
APPROVED BY: r� "" ` DATE: 2"'
COPY GIVEN TO' UT ITY BILLING (only if new meter) ❑ PUBLIC WORKS ❑ ENGI E RING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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