P - 39617Engineering WATER AND SEWER Permit No.:�'� �'
763-572-3552 PERMIT APPLICATION Received By
763-571-1287 fax CITY OF FRIDLEY DateRec'd: !
EFFECTIVE 01/01/201 I
APPLICATION DATE:,� f` _ YOUR E-MAIUFAX: _
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
.IOB ADDRESS: _ �� (9-�,� y/ ��� S %' /�-_�� �
NEW CONSTRUCTION PERM[T# (IF APPLICABLE):
PROPERTY NAME: GU� /bP �,� p a> � r� �--
OWNER/ ADDRESS: �rSG/�Yl �P CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR NAME: ' �� � c. �--v
SUBMIT A COPY OF ADDRESS: ��(�, L�. Q C[TY
YOUR STATE i-° "1 l �.�j/Vl �Q--� STAT � ZIP SS 3�/a
LICENSE WITH PHONE� (��� ._�-�'°7�'ip7 1 Z-- CELL PHONE: cD I�� z�� "� ��`� �
APPLICATION
STATE LIC # STATE BOND: EXP DATE:
l. NarrativeJwritten description:
2. Please attach sketch showing curb line, utility line, buifding, etc. with distances on back page.
3. Stipulations: �� '-'� �-- f 1/
PERMIT TYPE
I' SEWER CONNECTiON PERMiT I SEWER DISCONNECT PERMIT $50
I.. WATER CONNECTION PERMIT I WATER DISCONNECT PERMIT $50
f WATER LINE REPAIR $40 ,C�j. �V
I SEWER LINE REPAIR $40
I ADD STATE SURCHARGE �5.00 for each permit �� 13 C�
I SAC CHARGE @ $2230 = �
TOTAL $ �" �
OTHER CHARGES (IF APPLfCABLE) 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
TH1S IS AN APPLICATION FOR A PERMIT-NOT VAL1D UNTIL PROCESSED
I hereby appiy for a water or sewer (new connection or repaic) permit and t acknowledge that the information above is complete and
accurate; that the work will be in f rmance w'sth the ordinances and codes of the City of Fridley. 1 understand this is not a permit but
only an application foc a per ' n ork is to s ut a p rmit.
SIGNATURE OF APPLIC` T PRfN AME: ��"'�x /Y ��� BATE: /' I
APPROVED BY: ..., � DATE: r �/
COPY GIVEN TO: 1. ; ILITY BILLING (only if new meter) ❑ PUBLIC WORKS l; ENGI EERI G
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
76�-572-3552
FAX: 763-571-1287