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AF - 42031J � • � City of Fridley, Minn. BUILDING PERMIT nat�: _.___March 15� 1966 ____....�. Ra.chard Miller Homes Richard Miller Homes ' _._...._...__ .....__._......_...._.____.._.....__. r: _.__._......_._...__.____.. _._._ B er __.____ Aaaress �8256 Monroe St. N.E. Address ._._..____._._..______. ._........_...�....___._..__.._. _......._.______._.._._...._..._._._ ,�.�d � S— N° 8709 LOCATION OF BUILDING No. _._228._._._.. street .__... ElY.._Street N.E. _........_..._..._..._.._..__. Part oi Lot ._._.� ____. ._.___.___ Lot ...�1..� �.�....._ Block __ll ...__._...._.._. Additian or Sub-Divisian __..__�r�$__�4��5..���..._.. Corner Lot _.__._.._..._......_ Inside Lot ._.._.?�...._..._.._.._.... Setback _.._......��____._._ Sideyard __._'Z�.�.r..14.� ___......_..�.�. Sewer Elevatiam ._.._.r_.__.._._.._..___._._..._.._.______...._..___._._ Foundation Elevation .__..__._..___._._......._:._....._ ._.. DESCRIPTION OF BUILDING To be v�a �: �Dwellin___�.__....� �t __3?�' nepth _...__??�' Height ..... 20 �- &1. Ft. 816 �,,, � 16 320 _.�.�t:__.�ara.g.e .._ Front ___llt_ nepth _.._. 2�� I�eight ._.._10.�._ Sq. Ft. _..�_ cu. F't. __.2...,,._.6.�.0 Type of Construction _._.._._...._..___.._._...__..._._._. Es� Cost �15� 000.•-.._.__.._......_ To be Completed _..._.._..�... Ea canaideration o! the issuance to me of a permit to c tru the th� propoeed work in accordance wlth the d�acription abov f c�rdinanoea o! the city of Fridley. in I agree to do provisions o! In consideration of the payment of a fee o! �._.._1.��___.._.�pernsit is hereby granted to �-chard Miller Homes _ to construct the building or addition as deacribed above. This rmit is granted upoz� �._.�........_......_...._....__�----�-�-_ _ the expresa c�dition that thepe reon to whom it is granted and his agents, employees an workmen, in all work done in, around and upo� said building, or any part thereof, shall coffiorm in all respects to the ordi�►ances oR Frldley, Minnesota re8a�6 lxatian, construction, alteration, maintena,nce, repair and movin8 of buildin�a within the dty limits and this permit may be revoked a t any tin�e upoa� violation of any of the provisians oi said ordinance8. AI�EDT G. JENSEN g�� �p�� I� NOTICE: TMs p�mi� dea not eowr fh� eonstrualloa. M�a11�Non fer wlrL�y� PluaibinY� Ya h�aHno, awK er wat�r. !� wn fo sM f6� WiMieo Intp�elo� hr ppuaN pan�Ns for 1h�n i�amr. a , . APPLICATION FOR BUTLDING PERMIT CITY OF FRiDLEY, MINNESOTA OWNER' S NAME___ ��� � ,� �..�, � BUILDER � ADDRESS ,� � S f� ��-��-- � . ADDRESS LOCATION OF BUILIIING N0. '�� STREET PART OF LOT LOT .j �'� � L BLOCK i/ ADDITION OR SUBDIVISION�_ �, �� r�� GORNER LOT INStDE I.OT�_SETBACK �� SIDE YARD S�- % U SEWER ELEVATION FOUNDATION ELEVATION Applicant attach to this form Two Certificates of Survey of Lot and proposed building location drawn on these Certificates. DESCRIPTIOft OF BUILDING To be ed as ; , ' Front •� Depth G� Height y�� Sq. Ft . ,� �� Cu. Ft .'��� : - Front Depth-�,�-�-Aeight� Sq. Ft.�. - Cu. Ft. , � � Type of Construction Estimated Cos /�.� � O� To be completed The undersigned hereby makea application for a permit for the work herein specified, agreeing to do al?, work in strict accordance with the City of Fridley Ordinances and rulings of the Department of Buildings, and hereby declares that all the facts and representations stated in this application are true and correct. DATE S-- J S_ � 6 SIGNATURE � r�Q . �� �� (Schedule of Fee Costs can be found on the Reverse Side), � I � �-;� • � .. ,. ,. _, � � I • • � � . ' �3-�i1�-991�Q�1 . �il�`'�1 i`r�t �i IGT�t% � . � �t 4 R .��.• a„� r�r 5.3a�.i:� �!�i 1'. ���it:�19 • ' . , ��'lr�iC;'i:l�?� B�.'� ��U� c::�:::� �.,�.,�t � � • �,,,;,..,,,,,._—.......,_..r popt. of Bldp�s. phono S:.'�•3;50 D�SC�IP7IOti 0: �';�I�r= � � ' L� . �.!: 2�u�`�.�:. ::i.:3 a.zd Lec':f�» OS F!:!l�szes , ., • • j c�cy ot �-;a.i�y; "' R z o e 1 w�tt� ws�. Z:� z ?� r.zt�� �zi�z aa , �� z '� . ' � _ _ ` � 8 � � < � 7 � ,7 '" r ►+ r�s «tc. 'The undcrsigned hereby zrakes s���cation tor a Fe��t fcr th� vo:Y hu� 0 1<� � - i��, �� i� : o w��� � u� u �, o$ � s eci:i:d, a� eeing to do a�1 ��•c: k!a s:: ic! �cco:��,^.ce w•ith t1ie Ci� Q:'�ir.:r. in i s ��. � 1 �� N, � � P a.^.d ruIing oi 2he Dc:pa::mcnt o f Lui l�.'a�, a a.a. h e r e b y C e c l a r e s t h a t a. i L' � � t� $ 3•r I � •, and rep:esrr.t,:tioas s:atc-d !:•`::� ZDF'�cai:as are true �nd concti`t' . . � _ . 5-17-76 ls_ 1,� I I.. `_ r'�.-+'.dley, L:ian 2-, " —" �lar:�nc� "od1�T�rski ' . =�y , ( CYwncr ' 3:C � S:� ' . Kind oi B:sild'.ng _ • - Cc: : .s::.d �ii::. • F.`c:o Cc:::.:ua Cr�c'...• uc�aa: (] Uacd as t?{av Fi:::vra. O:d G}a:i^.�s Cc::�col � • � �.�....._�.. - • ' i0 VC Co:T�plCted `a�Ut 7-2i�-76 PARTlAL RATE S�HEDUi.E : L�:32t1C f'I:C?J'E RATES: . N�. RA'i'� . TOTAL n�.'.ST.tiJCT �XiUCCS•••• �••�►••••••• ��.+ X v�•G�. �J - Fti;u:e Flxture npening ........ ... ._._._-- x 51.58 S, -• — . 1tW Fixt�re Oii OyP1'JIl$• �•� • • i�• • • • ..�.� x 51.5� :"'�..�. C�tch Basin • • • • • . � • . • • • � � � • • • a • ��� X �.25 = tiv:tet }te:ter �L'p to �-3.0�? BTU�•••• ------- x ;3G0 S - ' • :�e�+ C:ou�d Run 013 B:dP. . . .:. . •. • _----._-- x ;3.25 S E:iC�C�.Cvia:�t. �i�.ltil�•••�i�••••��• ��z ��•� $ i7S :Z?TS:iG FEE3: ' HO. Fi)+::: T07AL • 1st3Fixtures .••••������••••••• �.,���XS2.� � . !►�: ltl�nal FYxtures . . . . . ..... . . . . . ----- x $ .75 S G:s R.:: ;r to 1�3.OG0 H;V ..... ...... .----.-..- x SS.CA S -- E5111t:3i(.'d CASt, s � O O� e�rnit No. P.:�:t h'a. `� � Old--A'nm¢xFlui:cting P , � $izr,cd �� . . . . MiNr�EC^��� -- . . . �Y� -- Busin��.s ��:.e �o . RCUGH FINnL �/ -(� - % � • 0 . .50 State Surch�=5e PS?i:.°•3 k AL:F°J�71�NS—P.�:er to Cods .. .�:CTSy'.iOA •�� • • • • . • • � . ► . . • : • • •.. . • . �.• • . . ...r...• . .S - • . . . � • �r�+ �.:L =� � � . .... . ._ . , . . . . . ' � � � ' • . 0 � • • • � • � SUBJECT P c�ty of Fridley _- 16 0 0 8 AT THE TOP OF THE TWINS g U I L D I N G P E R M I T r ; � � RECEIPT NO. � • COMMUNITY DEVEIOPMENT DIV. � � L_����� , r � � PROTECTIVE INSPECTION SEG � � i � � /'��1 � CITY HALL FRIDLE� SS432 NUMBER REV. DATE PAGE OF APPROVED BY � � ----�: `.� 612-571-3450 9i0-F15 11/14/80 � � JOB ADDRESS 22g Ely Street N. E. t LEGAI LOT NO. BLOCK TRACT OF ADDITION SEE ATTACHED oesca. 31, 32 11 Spring Brook Park SHEET 2 PROPERTY OWNER MAIL ADDRESS 21P PHONE Clarence R. Godlewski 228 Ely Street N.E. 786-7628 3 CONTRACTOR MAIL ADDRESS * ZIP PHONE LICENSE NO. �' `. 5ame d ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE IICENSE NO. 5 ENGINEER - MAILADDRESS ZIP PHONE LICENSENO. 6 USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE X 8 DESCRIBE WORK Construct a 34' x 10` Addition - Sidin - Reroof 9 CHANGE QF USE FROM TO STIPULATIONS 8� f�r �� �����'��;��� SEp�, rELfpH�NF �n� c�: ,j . � f � y R T . Fc��,-..�"`� :,; ,; t,,<<�;�s �.�T/�� � p�R �,�.Q����� � j.,_ �;r,`s � Ftc. � p� ���M,TS R� . � Y L,� 1� /�� �N� v'RFo S'��S FO� ���4 //�G, , TYPEOFCONST. OCCUPANCYGROUP OCCUPANCYLOAD SEPARATE PERMITS ARE REOUIRED FOR ELECTRICAL, PIUMBING, HEATING, VENTILATING OR AIR CONDITIONING. THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SQ. FT. CU. FT. AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION �' STALLS GARAGES AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION SURTAX AND ORDINANCES GOVERNING THIS TYPE OP WORK WIIL BE COMPLIED $10, 550 $5. ZH WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO GIVE AUTHOiiITY TO VIOLATE OR CANCEL THE pERM1T FEE SAC CHARGE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING coN- $66.00 NONE STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. PLAN CHECKFEE TOTALFEE $16.50 $87.78 /SIGNA REOFCONTRACTORORAUTHO �n NT io 7Ei HEN PROPERLV VALIDATED THIS IS YOUfi PERMIT %\ � � � L � � �I ` I ir�7 ,Jr_.C,,. � •�, J f—Y Si ATURE OP OWNERUi OWNER BUILDERi �DATEI BLDG WSP DA7 0 _ . : �;�.�, CI7Y Of' �i�IDI_EY . Af f'!_i(;(1'fIU;� F'Gf; ;'.l�.`aIi)(:�i��TIi";L PJI! UIi;G I'CR��ITS � � (I�e►•t,_l;ll:c;r�iit�n�, �ddiCi��ns, or Rcpairs) . � ai•�i�r-.a: G�����c�.__�___(�'�,��.�ws��M hui�o��: . ��t� � � - ��r��rss: ��� ��'/'� s�- �v � nonr�ess: . TCL h0: �— ��v�-� T�L PdO: ' Cons�;ruction Location ' . s�iz� � rlo : ��c`� s2�r.�1r.�: � Lc���: . �� � �- � ,2 Bz�oac : �._.... �_ � . . �nnz�rzata : SPRI A1 �'r- �'�CY� � ��� t�' ��rncr I.ot: Inside LoL-: SetbacY.: Sideyards: Ap�l.icant attach to tiiis forn t�ti�a Certif.icates �f. Survey of loti and prc�posed building tocation clrawn on certificates to scale. DESCRIPTIOit OF CU,dSTRUCTIOPd - � / � � ��.� � I'r�nt: ^�� � y Depth: /� Height: �o� ..._.____�._ ' � .L'' �► Q�N G Square. Feet: 3`� Cilbic. £cet: .4 �c—z 2CX1�= ��G' � ront: Depth: Heiglit: Squar.e I'e�t: Cubic I'eet: � - �Q, �� 'a'j�pe of Construction :�%� f"�� �Y� � Estimated Cos �: $� �ZWL[/ `ib Fc� Cor,�plet.ed: � Alt. A Alt. B k�ronc+sed Dzive�•�a1f T�ridth Tf 2dew Openinq Is Des_ireci: $� $ w , , SE� R�VE:RS�' SIDc OF SiI��.:T � �iic� unc�r�rsigned 11e�-e2�y :na};e:� applic«tzcn for a pern:it fcr. the �:�ork iierein speciiier3, �rreei.ng ta da ,all work iri strict accardar.ce t��i.tli i:�le City of. �ridley Ordii�zn�e� ai1�� rulings of i:lze DE�l�aa:tnic��t. of I3uil.dings, aric; hr.reby der.lares i:haL- all the i:ac�s and z�c�prt:�senl-<tti.ons s�atc�d �si this ap}�lic�:t.ion are true �ici corre�t� /, /� ., , n.:rr: �__. � `- �'0 sxcNn�rv�:��: �:t:L�::1�c1�:.JOZIS : ��.ti� z (oC� .00 . pL 1�.Sd � �a� ��•� $ . 3�v x 3/ Oa--- � l�, �y b�$ �:��--- �. � �. . ��.«�,��,�, -°.�„�..�. ,.,�-�.:a a ; 't vr # ;s w° -r-� ''�. z x-� ;�. - - ,-�=� `c�:^ � -az, �- � r ar�� �... ,�,,. -�����r � ..,.�- : - .. �' . - ��, � s _;.. ..:.. _ - -�� • � „a„ � '.� � � � '� � �� �� �-.�..s�'� !� . ,..-.. W � y,,,,.,;, ", �--."� . .s c._ . _. ,d•� .� ._ »�.� �,� ..s- ' .,,...�.�. �=�""" , . ...,. � : � --- .� _r. 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FRIDLEY, MINNESOTA 55432 • PHONE (612) 571-3450 May 24, 1989 Owner/Occupant 228 Ely Street N.E. Fridley, MN 55432 RE: Skateboard Ramp under Construction in Alleyway between 200 Blocks of Liberty and Ely Streets Dear Owner/Occupant: Recently it has come to our attention that a skateboard ramp is being built and stored on City property at the above-referenced site. As the City is responsible for the health and safety of its citizens, and general maintenance of its property, we must require that this construction cease and the materials be removed immediately. This is necessary to keep the alleyway free of debris and prevent risk of damage or injury caused by this activity. If this ramp and any surrounding materials are 22, 2989, the City will take action to reso2ve call me at 572-3595 if you have any question this further. Thanks for your cooperation! Sincerely, Steven Barg Planning Assistant SB:ls C-89-288 not removed by June the problem. Please s or wish to discuss CITY OF FRiDLEY INSP£C7tON D�V. fi431 University Ave NE Fridiey, MN 55432 572-3604 Stories Basement Floor 1 Ffoar 2 Flaor 3 Floor 4 PLUMBING FIXTUFiE RAtES: Urinal MARK Shower NO. RATE New Fixtures � Qld Opening, New Fixture BeerDispenser +, Blow Off Basin Catch Sasin � Rai� Water Leader Surnp/Receiving Tank _� Water Trea#ing Appliance �,_ Water Heater –Eiectric ' Water Heater – Gas** � Gas Range*� � Gas Dryer** _._._._ Back Fiow Preventer Required ( jYes () No Type $ 7.00 $ 4.00 $ 5.00 $ 7.00 $ 7.00 $ 7.00 $ 7.00 $10.00 $ 7.00 $10:00 $10.00 $10.00 $i5.00 Effective On August 1, i995 APPlICATiON FOR PLUMBING AND CAS FiTI'ING PERMIT OF FIKTURES TO BE iNSTALI.�D ON EACH FLOOR ` Wash i�iC�,� "' F(oor !G�h ; Auta, �iq�� Gas . Trav �bk�. ,� Drain !�tr� ' Washer ,��t. . ' Ran TOTAL Reinspection Fee $42.00/Hr ' ALL OTHERS ANDIOR R�PAIRS AND ALTERATiONS 1.5% of Vatue of Fixture or �tppiiance �i , c' '� State Surcharge TQTAL FEE .50 Water Heater Gas Elec JOB ADDRESS � �6 _ � The undersigned hereby makes appticatian for a permit for the work herein spec'rfied agreeing to do all wark fn strict accordance with the city codes and rulings of the Building Division, and hereby declares that aU the facts and representations stated in this applicat�on are true and cotrect. � % � , 1995 Owner C��.,G Y`- c:C. ����c � ��� -� �,�-f ,� g �i � `�l 4 � �j Buiiding Used As .�-:�I�/ l=�.�s 2.� Estimated Cost �C�i • UO PERM#T NQ. �/'�j���(,� PLUMBfNG COMPANY -c� ,r- � ��-��— . StGNED BY�`-�K--��-- TEL N0. �S�-�C' ��� � APproved By Rough-In Date Fnal �ate �U• ��-� PLUS THE 3.50 STATE SURCHARGE **COM$US'fION A�fl SHALL SE pROV1DED PER UMC SECTION 504(A) AND TABLE 6-A. MINIMUM SfZE 9 5Q INCHES. � � SuBJEGT . � c;ty of Fridley k � AT THE TOP OF THE TWINS g U I L D I N� P E R M I T „ � �• COMMUNITY DEVELOPMENT DIV. �,,s^� r � y � PROTECTIVE INSPECTION SEC. �����v�,/��� 1 � � � �"'1 � CITV HALL FRIDIEv 55132 NUMBEP pEV OATE P�GE oa �""'�' ,'' 612--571-3450 9t0-Ft5 9/24/O1 � � 10B ADDRESS 22g Ely Street NE 1- LEGAI �OT NO. BLOCK TRACT OR AODITION �esca. 31,32 11 Spring Brook Park 2 PiiOPERTY OWNER MAIL ADORES$ Clarence Godlewski 228 Ely Street NE 3 CONTHACTOR MAIL AOORESS Same 1 ARCHITECT pR OESIGNER MAII ADORESS 5 ENGINEER MAII AODRESS 6 USE Of BUILDING Residential 7 CLASS Of WORK ❑ NEW O ADDITION ❑ ALTERATION 8 DESCRIBE WORK Reroof House & Garage (23 Sq) Tear-off 9 CHANGE Of USE FROM TO STIPULATIONS 21P ZIP ZIP 32194 ��y 'opOvEO Br SEE ATTACHED SHEET PHONE 763-786-7628 PHONE LICENSE NO PHONE LICENSE NO. PHONE LICENSE NO � REPAIR O MOVE O REMOVE Underlayment must comply with the State Building Code. TYPE OF CONST. SEPARATE PERMITS ARE REOUIRED FOR ELECTiiICAL. PIUMBING. HEATING, VENTILATING OR AIR CONOITIONING THIS PERMIT BECOMES NULL AND VOIO IF WORK OR CONSTRUCTION 20NING AUTHORIZEO IS NOT COMMENCED Vy�THIN 60 OAYS. OR IF CONSTRUCTION OR WOiiK IS SUSPENOED OF ABANOQNEO FOR A PERt00 OF 120 DAVS A7 ANV TIME AFTER WORK IS COMMENCED. NO OWIG. UNITS I MEREBY CERTIfV THAT I HAVE REAO ANO EXAMINEO THIS APPLICATION 1 AND KNOW TME SAME TO 8E TRUE AND CORRECT. ALL PROVISIONS OF �AWS yq�UA710N aND oaDiNnNCES GOVERNING TriIS TrPE OF wORK Wi�L BE COMP�iED WITM WHETMER SPECIf1E0 HEFEIN Oi: NOT. TME GRANTING OF A PERMIT �2�465 DOES NOT PRESUME TO GIVE AUTHpqITV TO VIOLATE OR CANCEL TME pEqMIT FEE PROVtSIONS OF ANY OTHER STATE OR LOCA� LAW REGUTATING CON- STRUCTIpN OR TME PERFORMANC6 OF CONSTqUC710N $H3.2S OFCON'PACTQRO���.A/`" ' ID1TEi . E -�.�-K., � � Y� � . )� OWNEQ ��� OWNEA 8U�l0Eiii iDATE� BIDGi OCCUPANCYGROUP OCCUPANCYLOAD SO.fT CU FT. OfFSTREET PARKING STA�LS GAiiAGES SURTAX $1.23 S C CMARG ire C $2.47 TOTAL F E �% $8 .95 i E � N� [ l Effective 1/1/2001 ADDN [] ', CITY OF FRIDLEY (763) 572-3604 Bldg Insp ALTER [] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION Construction Address: �� c� � Legal Description: Owner Name & Address: � Tel. # �7��- 7��� %�� � Contractor: c� c� s� ��, MN UCENSE # Address: ,.�:� �- ��.:� Si— •��_� �r 1 d ( � Tel. # LIVING AREA: GARAGE A�REA: DECK AREA: OTHER: Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF IMPROVEMENT Length Width Height Sq. Ft. Length Width Height Sq. Ft. Length Width Hgt/Ground Sq. Ft. r j 1�� o �� � ��d �S �.? 'r �,8..� A�- f c Construction Type: �a�t r.� � Estimated Cost: $ ��� �" Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft =$ DATE: �-dt� C�/� APPLICANT: � Tel.# �7��-7��J?�� d' CITY USE ONLY - Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Park Fee Sewer Main Charge TOTAL STIPULATIONS: Call (763) 572-3604 for Permit Fees if mailing in application $ �.3- ��r Fee Schedule on Reverse Side $ - `�� .001 of Permit Valuation (1/10th%) $ / � 3 $.50/$1,000 Valuation $ $1150 per SAC Unit $ $5.00 (State Licensed Residential Contractors) $ Alt. "A" or Alt. "B" Above $ $450.00 Conservation Plan Review $ Fee Determined by Engineering $ Agreement Necessary [ J Not Necessary [] � . S� M ' � , Engineering WATER AND SEWER Permit No. t � 7b3-5�12-3552 PERMIT APPLICATION • e�� 763-571-1287 fax CITY OF FRIDLEY a�ec'd: EFFECTIVE 7/1/2010 APPLICATION DATE: � " / �` �L5 YOUR E-MAIUFAX: / �� — � '" � . � _ THIS APPLICANT IS: O OWNER �LCONTRACTOR JOB ADDRESS: L NEW CONSTRUCTION PERMIT# (IF APPL ABLE): PROPERTY N�: i ` ` � OWNER/ ,�DRESS: ��`6 j",ur S7 CITY STATE ZIP TENANT PHONE: CONTRACTOR NAME: � ! SUBYOUR STATE OF '''DDRE . ` ITY ' STAT�i1 ZIPL��j�Z LICENSE WITH PHONE �� `�-t L�—C�~J �� CELL PHONE: � Q�% APPLICATION STATE LIC # STATE BOND: LS %� EXP DATE: 1. Na ative/written descr' tio!� � c�� 1 V` n T. �' i" '�- t/J �- . L E�F� !L/f�/L eiJfL� S�i7l� c-�- 2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page. 3. Stipulations: r- t''���� C'�� � 'S G�Q � Z. ` Z� � S�? - s PERMIT TYPE ❑ SEWER CONNECTION PERMIT $50 ❑ WATER CONNECTION PERMIT $50 �WATER LINE REPAIR $40 y�j • �x7 � SEWER LINE REPAIR $40 ❑ ADD STATE SURCHARGE $s.00 ,�-va ❑ SAC CHARGE @ $2100 = �5 ,00 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 APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED I hereby apply for a water or sewer (new connection or repair) 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 rmit and work is not to start without a permit. SIGNATURE OF APPLICANT ---.�-..�.-..- PRINT NAME: "1 DATE: �— � —�� _._.__ _ � APPROVED BY: DATE: � �� � O COPY GI N : � TILITY BILLING (only if new meter) ❑ PUBLIC WORKS ❑ ENGINEERING City of Fridley Engineering Department 6431 University Avenue NE, Fridley, MN 55432 763-572-3552 FAX: 763-571-1287 �� . �� Z � o �- s �