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P - 74946� 7y�" CITY OF FRIDLEY � WATER AND SEWER CONNECTION PERMIT APPLICATION Name: � L L C-� r%� � L Date: �� '/ 9 19� (Homs Owner or Plumber� �Q Job Address: �� <-f}.�T ' v��2 LOT NO. BLOCK TRACT OR , DDITION ,1 LEGAL DESCRIPTION � _a9 � ,�/��N�� ,[��2eY�� /"fi�P�� PERMIT: � SEWER: FEE• °�'S � �� 0-DAPTER: STATE , SD SURCHAHGE: t � TOTAL: aJ ..— WATER: METER: FEE: �S� DEPOSIT: STATE c�� SURCHARGE: � TOTAL: /�'' � S OTAL: '�� / 0 0 GRAND TOTAL: S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: NEW STR URE: BUILDING PERMIT NO.: °?�`�r $EWF�� ,�ER�IT,,fI�.: { �� / ( `/ SPECIAL ASSESSMENTSirL��'-� �'' . 6ieried� �-t� il ,.t(/�..tti.---�