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E neering WATER AND SEWER Permic No.: �� r��t��
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7� -S%2-3552 PERMIT APPLICATION Received By: �''' ���,_�_
�16�-571-1287 fax CITY OF FRIDLEY , � �� - �
EF�ECTIVE 10/27/2010 �����„_
APPUCATION DATF: I��" L� �� l�" YOUR L-MAIL/FAX: _ —
THIS APPLICANT IS ❑ OWNE ONTRACTOR/'�/'
.IOB ADDRF.SS � �� / / � (�1 r/� � �C%� �------- —
NEW CONSTRUCTION PERMITlt (If APPI.ICAC�LF) _. _._ _._________ --__— _ -- -
PROPERTY NAME ,/ " —
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OWNER/ ADDRESS � Z I � LC�'L.12 --C'IiY-------f—��l�/ L G%_ STATE__ZIP
TENANT pyONF l.� %� z��' 3���
CONTRACTOR NAtvtE: � � ` ..�,/��� �� � /� ��C----�
SUBMIT A COPY OF ADDRESS � % 7 � '��"��`•= ��c.._ CITY ;�-f ��"`"� `" STATE .�!�`•?_IP�S �'=" (
YOUR STATE — - /
L/CENSE WITH PHONE --- CELL. PIiONE: __�,�__�5��!��L?� �—
APPLICAT/ON
STATE LIC # S'iAT[. 130ND I XP DA 1'L
1. Narrative/written description:
—�;�.�t ` %� L L � ' ,^ c � w4 /�"�' i T ��
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations: ��if%7���%/O•'U C�� C.��� I 5/ (i� r(�/L��C=7/� fJ`� ��C� �Z J�2S �
z _ ��v � ����-r ��,�� � � .-�-� � �.,� �-T ��N �3 � �z ��: � �°" .
[+,r �%L t�/�'► Bi.�/L• /� F.;v2.v1 i j,
3. L�f� �� P�'����' = � ��c� � �-7,���J
PERMIT TYPE
C SEWER CONNECTiON PERMIT - SEWER DISCONNEC"I� PF.RMI"I� $50 __
I WATER CONNECTION PERMIT SEWER DISCONNGCT PGRMIT �50 ___ _
,.:�"`WATER LINE REPAIR $40 �'
_ SEWER LINE REPAIR $40 _ _
I ADD STATE SURCHARGE $_5.00 for each permit ��� ��
'_ SAC CHARGE � $2100 = _
TOTAL $ �-� S� O c
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY' BILI_.ING
NEW WATER ME��ER COS"1� - SEF U"TILI"['Y BII_,LING
SPECIAL ASSESSMENTS - SEG I�INANCE
WATER TAP - SEE ENG[NGFRING
NOTE: WATER METER REPAIR, [NSP OR S}-IUT-OFF J EVENINGS, wEGKFNr�s & Fiot..i�nvs $1251HOUR-B[LLED
THIS IS AN APPLICATION FOR A PGRMIT-NO'I' VALID UN"�IL PROCGSSED
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 Ciry of Fridley. 1 w�derstand this is not a permit but
only an application for a permrt and work is not�fo start without a permit.
SIGNATURE OF APPLICANT ' ` "�'" �I _PRINT NAMf . � �7`�L -�L'� l� _ DAl'L: � �` `!D ' /�
.- , � / Z -/C� - � i
APPROVED EiY: LZ ' - � -a�__ _ _ DATE.
COPY GIV�`� T� -1 UTI�,ITY BILLING (only if new meter) -1 PUBLIC WORKS - ENGINEERING
(;ity of r r�qley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
7C3-572-3552
FAX: 763-571-1287
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