P - 48580Engineering WATER D SEWER Permit 1vo.:
763-572-3552 PERMIT APPLICATION Received By:rr�'�
�ITY OF FRIDLEY �� M � r��
763-571-1287 fax EFFECrivE ovia.rioiz Date
APPLICATION DATE: YOUR E-MAIUFAX: t�! �� S"" ���"3 _
THIS APPLICANT IS: Q OWNER FI`�CUNTRACTOR
JC)B ADDRESS: �—� i I � �� Q— O�.1C:�
cy �— �,
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY Np�: �
TENANT ADDRESS: �` I ( �I4C�R�a�J"C �,`Z�L_I�C�ITY �-�.5�.-� STATE �;P ��;
PHONE: 't'�1P�7"�'�''—I.Z L So
CQNTRACTOR Na1viE: �i -�G2E1..�2rv� '�v-fl��-t �'r" ,.5 -
;SUBMITA COPYOF �DRESS:_ 'r'Z� � tQC?2 '�� CITY ��'C.,. �4v�.� STATE �IP SSt t`*f
YOUR STATE � r�•-- ��
LICENSE WITH PHONE _(��'( —C.a�—lS ` ��'�-2CELL PHONE: �C1,2'�S ^' `(�-�_ -:
APPLIGATION
STATE LIC # �?i'v1 STATE BOND: EXP DA'i'E:
1. Will work take place in City ROW? Yes � If yes, ROW r�gistration is required - see Er�gineering.
2: Provide written description of proposed wor :�' �.a-t iZ.,��w��cZ.
_—�-._
3. Atta.ch plan/sketch showing proposed work with existing curb, utilities, trees, buildings, etc. with d.iYnetxsiQr�s
4. Circle type of erosion control measures to be installed to prevent disturbed soils from emding:
Silt Fence Bio-rolls Erosion Blanket �odding Other:
5. Provide minimum of 2 hr notice for inspection ( 8 am - 4:30 pm) and call in the following o�rder: (7�3) Si2-
3552, (763) 572-3556, (763) 238-8058, (763) 572-3562 or (763) 572-3551, or (763) 427-1�12.
6. Refer to "Construction Requirements for Water and Sewer Work" on back of page.
'7. Stipulations:
' PERMIT TYPE
0 SEWER CONNECTION PERMTT ❑ SEWER DISCONNECT PERMIT S50
❑ WATER CONNECTION PERMIT ❑ WATER DISCONNECT PERMIT $50
�SEWER LINE REPAIR ❑ WATER LINE REPAIR $40 _ _,_„
0 ADD STATE SURCHARGE $5.00 for each permit
❑ SAC CHARGE @ $2365 =
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 wEExENDS & HOLIDAYS � $125iHflUR-�iL D
THIS IS AN APPLICATION FOR A PERMTT-NOT VALID UNTIL PROCESSED
I hereby apply for a water or sewer permit and I acknowledge that the information above is complete and ac�urate; tttat the w will be in
` conformance with the ordinances and codes of th$ City of Fridley. I understand this is not a permit but only an applic�tian fo a pernut azzd
work is not to start without city ap roval i rffiit ap lication, unless emergency repair is required.
` SIGNATURE OF APPLIC Li �� PRINT NAME: r� U'{�L�f37 DATE: �' �z--
APPROVED BY: " AATE: _ } / �
_�
CUPY G N TO: ❑ UT Y BILLING (only if new meter) 0 PUBLIC WORKS ❑ ENGINEERiNG
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763=571-1287 '
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