P - 84233Enginee�ring WATER AND SEWER Perm�t No, ` �,
763-572-3552 PERMIT APPLICATION Received By: �
363-571-1287 fax CITY OF Fi2IDLEY Da �`
EFFECTIVE Ol/12/2012 �
- APPLICATION DATE: 3' 2 6'� o ��. YOUR E-MAILlFAX: d r f Gd U�� h I�!'n � i� c. �d r�
TfiIS APPLICANT IS: ❑ OWNER �CONTRACTOR �
JoB ttDDltE,sS: SY!►o � t a o n J7v' . -
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NEVN CONSTRUCTION PERMIT# (IF APPLICABLE):
FROPERTY NAME: �/ v, n /; n
T�N�� ADDRESS: S�Ib(% /7�D/'r 2o h r• CITY �rr Gj �� `ti STA'1'� 1d!�i�+ S� � �
PxorrE: 76 3- Sn - 9y 2.�
C{1NTRACTOR NAME: �+-r�. ► n �� r�►g, 'F � c
SUBMIT A COPY OF p�DRESS: ���� l� � t� c� S'f • CITY �� �"ei � C STATE �ZiP` �y3�
YOUB STATE
LICENSEWIT`H PHONE '763'���' 30Od CELLPHONE: _Ioi��363-5 S2
.�l�'PLICATIDN STA1"E LIC # STATE BOND: � Q b�'I b 0 CI �T EXP DATE: 1� r 3� 2- ��,� `
l. Wiil work take place in City ROV�J? Yes No If yes, ROW registration is requiz'�'i �- see Engit��erin�g.
2. Provide written description of proposed work: �e ja�1�� 11�.r,c�r %�� Su�%�� c lr.� . a,� t%n
�r;� w0. J � $ �- ��. .
3. Attach plan sketch showing proposed work with existing curb, utilities, trees, build��gs, ei�. �i� din�er�sions �
4. Circle type of erosion control measures to be installed to prevent disturbed soils from e�ding. ��
Silt Fence Bio-rolls Erosion Blanket Sodding Other. '�
� 5. Provide minimum of 2 hr notice for inspection ( 8 am - 4:30 pmj and ca11 in the followirig c�rder: �763) 5"i2- `
3552, (�63) 572-3556, (763) 238-8058, (763) 572-3562 or (763) 5?2-3551, or (7b3) 427-1�12.
6. Refer to "Construction Require ents for Water d Sewer ork" an back af e:
y
7. St1P111tif.lOi1S'
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PERMIT Ti�PE
0 SEWER CONNECTION PERMIT 0 SEWER DISCONNECT PERMIT $50
� WATER CONNECTION PERMiT ❑ WATER DISCONNECT PERMIT $SO
� SEWER LINE REPAIR ❑ WATER LINE REPAIR $40
� ADD STATE SURCHARGE S5.00 for each �rmit � �'"
❑ SAC CHARGE @ $2365 a
TOTAL $ '�
OTHER CHARGES (IF APPLICABLE} PAY TO UTILI'�"Y BIL`LING
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 $c HOLIDAYS $125/H�3U�'-$R�L�
THIS IS AN APPLIGATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
£, I hereby apply for a water or sewer permit and I acknowledge that the information above is complete and accur�te; that tJ�e work wi3�� ii�it
conformance wi#h the ordinances and codes of the City of Fridley. I understand this is not a peimit but only ar� application i'ttr a p�trai�` �:
- work is not.to start without city proval of this permit applicarion, unless emergency repsir is required.
:SiQNATURE OF APPLICANT PRiNT NAME: /T�'"t I`� ll-lAAa-C' / DATE: 3� �# �
APPROV�D BY: DATE: �' �+� Z-
C��� (iNE �: 0 UTIL Y BILLING (only if new meter) � PUBLI�' WORKS 0 ENG�AiE�RIIYG
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432 �,=
763-572-3552
- FAX: 763-571-1287
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