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Engineering WATER AND SEWER Permit No.:
763-572-3552 PERMIT APPLICATION Received By:
763-571-1287 fax CITY OF FRIDLEY Date Rec'd• s' 'f �
EFFECTIVE O1/Ol/2011
APPLICATION DATE: �� IT�I �� YOUR E-MAIL/FAX: _
THIS APPLICANT IS: ❑ OWNER '�CONTRACTOR
JOB ADDRESS: ��Z9 C�14P���, (�IIG
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME: C�L-C��, t'�iA-Lwt,�
OWNER/ ADDRESS: 4�Z-� �P�2DE�)� r4C1L� CITY F
TENANT °'T � `�� STATE �MNZIP��.3'Z
PHONE: �-�3- �{3�I'"' C,R.��
CONTRACTOR NAME: ���� � "�.r.,� p+.,�.s-r0 T �.S
SUBMITACOPYOF ADDRESS: Z2'�-(. G4Q? iZ� C1TY ST. 2��t,tL STATEV�N21P SS��`"f
YOUR STATE
LICENSE WITH PHONE (�, 5L'"6�f.S-�j('oZ'Z CELL PHONE: Co�Z �-E�I,� -Li i-$q
APPLICATION
STATE LIC # p N'l STATE BOND: EXP DATE:
1. . Narrative/written description:
$� S'�oT ���i� bF �{ �� ��4�T '=2's�� S�_wG2_ L.��
2. Please attach sketch showing curb line, utility line, building, etc, with distances on back page.
3. Stipulations: �-�r� h ��} V/ S�p, � �e S 5 $� e�� 6 4 v� � S,. k C r e;� fJ' � c t f�/' fn e 0 r�
�' bP �� Cuh�� .(l� se p f a,qQ� C�w�pae�.`�� f e C���`9 u�e s� SG,�e �2xCp Vu�•�v�►
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PERMIT TYPE
❑ SEWER CONNECTION PERMIT ❑ SEWER DISCONNECT PERMIT $50
❑ WATER CONNECTION PERMIT � WATER DISCONNECT PERMIT $50
0 TER LINE REPAIR $40
SEWER LINE REPAIR $40
G ADD STATE SURCHARGE $5.00 for each permit
❑ 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 / EVENII�TGS, 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 not to start without a permit.
SIGNATURE OF APPLICANT y PRINT NAME: �`t" �`�-�"�S C DATE: l 1 J,_
� � (� Z3 1I
APPROVED BY: DATE:
COPY GIVEN TO: ❑ T L(TY 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
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