P - 48381Engineering WATER AND SEWER Permit No.: ?� I
763-572-3552 PERMIT APPLICATION Received By: ,
CITY OF FRIDLEY y�, ;. . .
763-571-1287 fax Date��: . �. � ���
EFFECTIVE O1/12/2012
APPLICATION DATE: �'' I':7 '` �•�; I�, YpUR E-MAIL/FAX:
THIS APPLICANT IS: ❑ OWNER �,CONTRACTOR
JOB ADDRESS: _ ��,,o� 1 �. us� �i V+2.� �(nl�
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY Nq�: � n��� E, l w�e.r
TNANT �D�ss: -'i 2.�C4 � r� � V E CITY_ r r� STATE�ZIP �' �,,
PHONE: � 7.,-• a.� O-q 3y �
CONTRACTOR NpME:�`��,po � nr��,w(�
SUBMITA COPYOF �DRESS: a�.�.-1� C�nAfJ '�c�c.r. CITY �", P<1,\L STA7"E'�1CiV� ZIP� l�{
YDUR STATE
LICENSE WITH PHONE CELL PHONE: �p ��` 1-i 9' O"�� O� ��5
APPLICATION
STATE LIC # �' 6�� STATE BOND: EXP DATE:
1. Will work take place in City ROW? Yes Qo If yes, ROW registration is required — see Engineering.
2. Provide written description of proposed work: a{}�,,,�� 5�.,,�.Q;}r
K 2 P a i,/ ��(`4 � 4 e.x� S�2 w��r (1r� r,�,� �-, � rn �(�L O �3 Y0 `� 15-� arz.� $�� i r.c. �..
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- Erosion Blanket Sodding Other: C:�2,�}35 ��-��-�
5. Provide minimum�a hr notice r 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 of page.
7. Stipulations: r'^
PERMIT TYPE
❑ SEWER CONNECTION PERMIT ❑ SEWER DISCONNECT PERMIT $50
❑ WATER CONNECTION PERMIT 0 WATER DISCONNECT PERMIT $50
�SEWER LINE REPAIR ❑ WATER LINE REPAIR $40 D
❑ ADD STATE SURCHARGE $5.00 for each permit �
❑ SAC CHARGE @ $2365. _
TOTAL $ �-F �-
' OTHER CHARGES (IF APPLICABLE) 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 SHUT-OFF / EVENINGS, WEEKENDS & HOLIDAYS ) $125/HOUR-BILLED
THIS (S AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a water or sewer 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 and
work is not to start without c' a pr val of this permit application, unless emergency repair is required.
' �h r � s v .. � • � b�/�% DATE: � � ` �V ` �� �iL,
SIGNATURE OF APPLICANT PRINT NAME:
APPROVED BY: DATE: Z- Z� Z
COPY GI T: D UTIL TY BILLING (only if new meter) 0 PUBLIC WORKS ❑ ENGIN ERIN
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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