P - 44949Engineering WATER AND SEWER Permit No.
763-572-3552 PERMIT APPLICATION Received By:
763-571-1287 fax CITY OF FRIDLEY ����r Q Q���
EFFECTIVE OiJ01J20] i —
APPLICATION DATE: � � 2'� i I YOUR E-MAIL/FAX:
THIS APPLICANT IS: O OWNER �-��EONTRACTOR
JOB ADDRESS: �-�/ SU G.,, �� J f {�' ��
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME: � 0 �--�
OWNER/ ADDRESS: �S5'D £, �, v•c r(Q � CITY �=�� t}��r�STATE ZIP
TENANT
PHONE:
CONTRACTOR NAME: (y (�F' "
SUBMITA GOPYOF pDDRESS: '% 7�T� �.. � CITY .� STAT ZIPSsj �i8
YOUR STATE
LICENSE WITH PHONE ��0 3 l�"� fj^ �� � Z CELL PHONE: f 2 - Z sc3 '-% 3'r'7 �`
APPLICATION
STATE LIC # STATE BOND: EXP DATE:
1. Narrative/ itten description: _ �/
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2. Please attach sketch showing carb ne, u►ity line, building, etc. with distances on back p�ge.
3. Stipulations: !� e �� �° � a,� � Yh � e t' �fv S7 �/`P e(� C' �t �' b t% �l' c� 6l e
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PERMIT TYPE
❑ SEWER CONNECTION PERMIT ❑ SEWER DISCONNECT PERMIT $50
0 WATER CONNECTION PERMIT ❑ WATER DISCONNECT PERMIT $50
� WATER LINE REPAIR $40
C7 SEWER LINE REPAIR $40
❑ ADD STATE SURCHARGE 55.00 for each permit
❑ SAC CHARGE @ $2230 =
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 REPAIIZ, INSP OR SHLJT-OFF / EVETTINGS, WEEKENDS & HOLIDAYS $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a water or sewer (oew connection or repair) permit and I acknowledge that the information above is complete and
accura.te; 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 n work is not to start without a permit.
SIGNATURE OF APPLICA PRINT NAME: �✓� /� (ca�°`i�-- DATE: �b�2a�//
APPROVED BY: `�� DATE: �v � � �i
COPY GI N Z'�: ❑ UTILITY BILLI G(only if new meter) ❑ PUBLIC WORKS C ENGINEERING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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