P - 36884Engineering WATER AND SEWER PermitNo.•
763-572-3552 PERMIT APPLICATION Received By•
763-571-1287 fax CITY OF FRIDLEY D��,��Y � Q
EFFECT'IVE O 1 /O 1 /2011
APPLICATION DATE: ���1 r YOUR E-MAIL/FAX:
THIS APPLICANT IrS: ❑ OWNER �EONTRACTOR
JOB ADDRESS: ( �D �i N QLk' �+�ra� �%r `� (-
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME: D� G1 pCoL!
TNANT ADDRESS: rO�S I�Q���� ��� �C CiTY ��? �C STATE Al�tiZlP �y��
PHONE: ��O' S3�f" D�.3�
CONTRACTOR NAME: ���2 1 ti�iks ��'t S
SUBMIT A COPYOF ADDRESS: c�� %D C4 �� � CITY �' �6r, STATF/I�iZIP S�'/�Y
YOUR STATB � •
LICENSE WITH PHONE ��l ` GY�— �d J-ol CELL PHONE: Gf2 ` �I 9O^ � 5 4�
APPLICATION p
STATE LIC #�6 Q�o P/t'l. STATE BOND: �`� �5��6 EXP DATE:
1. Narr�ive1wr�en desc�ption• �� � � `
� !k `'�' �I- +�-� .-n �ja�Y/�
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
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3. Stipulations:
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572-35�/ o
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� � � � PERMIT TYPE � 5?�2 ' 3 55 Z
❑ SEWER CONNECTION PERMIT � SEWER DISCONNECT PERMIT $50
❑ WAT'ER CONNECTION PERMIT �_; SEWER DISCONNECT PERMIT $50
^ WATER LINE REPAIR $40
� SEWER LINE REPAIR $40
❑ ADD STATE SURCHARGE $5.00 for each permit
� SAC CHARGE @ $2230 =
on
� 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, WEEKENDS & HOLIDAYS $] 25/HOUR-BILLED
THIS IS AN APPLICATION F�R 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 wor is not to start without a permit.
SIGNATURE OF APPLICANT PRINT NAME: �G� I �4 n a k 4 � DATE: S����
APPROVED BY DATE: � �Z
C�PY �i N T :❑ U ILITY 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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