P - 75011CITY OF FRIDLEY
WATER AND SEWER CONNECTION PERMIT
APPLICATION
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73
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Name: �'�,.r`''`.� i�b�v �r„,��.��,�,lJ Date:
=� 1995
(Home Owner or Plu ber) �
.�s a b� t�� C.�� nt� �� 6�-�,,.d-�,�
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Job Address:
LEGAL DESCRIPTION
PERMIT:
SEWER:
FEE:
O-OAPTE R :
STATE
SURCHARGE:
TOTAL:
LOT NO. I BLOCK � TRACT OR ADDITION
WATER: v
FEE: �:.� t CSU
STATE
SURCHARGE: , �
TOTAL: '�"�U
GRAND TOTAL: 'J i `� v
METER:
DEP061T:
TOTAL:
S.A.C. CHARGE ON EXISTING STRUCTURE:
EXISTING STRUCTURE: NEW STRUCTURE:
BUILDING PERMIT No.: SEWER/WATER PERMIT NO.: �g3
SPECIAL ASSESSMENTS: Signed: � �"1'` �! ���r� (���'
�c�� l�J�� � �: ) `
gy: ,� i� �