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P - 74950J .� � -- � ��. y , CITY OF FRIDLEY / ✓ WATER AND SEWER CONNECTION PERMiT APPLICATION Name: C—�Q p`� �� l�l ►�'� u� N G Date: �� 3 19 �� (Home Owner or Plumber) Job Address: � � 3 5 l-- �` �'� \�. ` -'�-C � �.J LEGAL DESCRIPTION �S % PERMIT: ✓� ✓ SEWER: WATER: METER: .5�' i'---� FEE: °�— � U FEE: �`� UEP061T: O-DAPTER: � STATE � STATE , �.� SURCHARGE: '�l SURCHARGE: TOTAL: `� v TOTAL: /'3�' `� � TOTAL: '4( GRAND TOTAL: �"� � C) S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: NEW STRUCTURE: _ BUILDING PERMIT No.: =2�� SEWER/WATER PERMIT N.• �: i'� _, � � SPECIAL ASSESSMENTS: Sign • BY: _ ��-�-,,