P - 36701Engineering WATER AND SEWER PermitNo.: ((� ��,��u�
763-572-3552 PERMIT APPLICATION Received By: Y�
CITY OF FRIDLEY ,
763-571-1287 fax EFFECTIVE 7/1/2010 Dat��d, �
APPLICATION DATE: � � � % �� YOUR E-MAIUFAX: �A ��'�.� rr�Lo �,+� � d �''� ��J`�� '�
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THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
JOB ADDRESS: S �/ �/�i � �'' 0••1 �' � % /�%. � .
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY N,�IviE: t'° i�/T� j/ Cj� /'',�� ,OL��
OWNER/ ,e,DDRESS: � 7 3� �% � � � S/ �Ty �'��Ty �-'.Pr.OL.�'+, STATE �''ZIP
TENANT
PHONE:
CONTRACTOR Na,,�.,G,e�rT,�Lo,r,�,� C'D..� �
SUBMITA COPYOF �DRESS: ��r � �vG� � ' CITY �T����` STATE�h7� 3��1�
YOUR STATE / / 'J
LICENSE WITH PHONE�P ��/—� y D�Li� CELL PHONE/� �� —2 7� `�
APPLICATION
STATE LIC # STATE BOND: EXP DATE:
1. Narrative/written description: �G �
n �
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations: ��,�- J�� �"-r/V
PERMIT TYPE
,�,s
� SEWER Cf� CTION PERMIT $50 �� ''�'
❑ WATER CO��IECTION PERMIT $50 �'p • '�—
❑ WATER LINE REPAIR $40
❑ SEWER LINE REPAIR $40
0 ADD STATE SURCHARGE $5.00
❑ SAC CHARGE @ $2100 = �
_�—
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 SHLTT-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 permit and work is n to start without a permit.
SIGNATURE OF APPLICAN PRINT NAMr�O� ��LL�i D.a�: // / 7 l�
,:. .. . s%
APPROVED B. �_ DATE: `v � Z �
COPY N :❑ UTILITY BILLING (only if new meter) ❑ PUBLIC WORKS ❑ ENGI EER NG
Citv of Fridlev
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287