P - 41410Engineering WATER AND SEWER Permit No.:�r L
763-572-3552 PERMIT APPLICATION Received By:�`�� �' !
763-571-1287 fax CITY OF FRIDLEY - j�-��
EFfECTNE 01/O1/2U1 I ���� � � " � � �
APPLICATION DATE: �� ' �l � % YOUR E-MAIL/FAX:
THIS APPLICANT IS: ❑ OWNER I�ONTRACTOR
.fOB ADDRESS: �� `f (� � i ��11 �
NEW CONSTRUCTION PERMIT# QF APPLICABLE):
PROPERTY NaME: r. � ��t . z � t�'r�y "�
OWNER/ ADDRESS: --� ��A,ry/� ,,,Q,�-' CITY STATE ZIP
TENANT --
PHONE:
CONTRACTOR NAME: ��� � �`� � �jc
SUBMIT A COPY OF ADDRESS: �� S~ ��L - /
YOUR STATE /� '1 CITY_j'(/,,4-�w�.� STAT �% ZIPS S3 f/(�
LICENSE WITH PHONE �tp �� �,� r 6`71 L CELL PHONE: �U I L�� Z S c� `' �� Sr'
APPLICAT/ON
STATE LIC # STATE BOND: EXP DATE:
1. Narrative/wr�i jte�n� d�escriPtion: �/ / �
'�r�r� c.�c+-.�. �Q .�� _� n � Ji��r.c.,.ra..L �'`--� v� �-c�-r��`- c�-7�'
2. Please attach sketch showing curb line, �tility line, building, etc. with distances on back page.
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3. Stipulations: � Z � /(J 2-
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PERMIT T1i'PE �
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I' SEWER CONNECTION PERMIT I SEWER DISCONNECT PERMIT $50 '
I. WATER CONNECTION PERMIT I WATER DISCONNECT PERMIT $50
I WATER LINE REPAIR $40
I SEWER L(NE REPAIR $40
I ADD STATE SURCHARGE $5.00 for each permit
I SAC CHARGE @ $2230 =
TOTAL $
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 IS AN APPUCATION FOR A PERMIT-NOT VAUD UNT1L PROCESSED
I hereby apply for a water or sewer (new connection or repair) permit and 1 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. 1 understand this is not a permit but
only an application for a permit work is n t to art without a permit.
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SIGNATURE OF APPLI /'lU DATE: �� / _
APPROVED BY: DATE: �
COPY G E �: ; U ILITY BILLING (only if new meter) l:i PUBLIC WORKS l; ENGI EE NG
iitv nf Frir�lPv
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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