P - 46952Engineering
763-572-3552
763-571-1287 fax
APPLICAI'ION DATE: NDL
THIS APPLICANT IS: ❑
JOB ADDRESS: `j� / �j
NEW CONSTRUCTION PERMIT# (IF
PROPERTY NAME:
OWNER/ ADDRESS:
TENANT
�
CONTRACTOR NAME:�
SUBMIT A COPY OF
YOUR STATE ADDRESS�
LICENSE WlTH PHONE�
APPLICATION
__ _ STATE LIC #
1.
2. Please attach sketch showing curb
3. Stipulations:
WATER AND SEWER
PERMIT APPLICATION
CITY OF FRIDLEY
EFFECTIVE Ol/O1/20J 1
YOUR
�`v��
Permit No.:
Received By,
Dat�i� dN
STATE ZIP
. . .� �iv` �
��-/ d'V OV I�`�Tl' /�lnLS . STATEW��!LIP �
c_1
�Z CELL PHONE: �/'Z -3��j --��3'
STATE BOND: EXP DATE:
r
o' �i, .r z` �Q�� �i h --P
utility line, building, etc. with distances on back page.
� • � �l ����2 76 3 Z38 Siv�l$
��3 23� $��
76 3 572 3�5�
PERMIT TYPE
❑ SEWER CONNECTION PERMIT �SEWER DISCONNECT PERMIT $50 _ �
❑ WATER CONNECTION PERMIT�WATER DISCONNECT PERMIT $50 _ r
WATER LINE REPAIR $40
0 SEWER LINE REPAIR $40
❑ ADD STATE SURCHARGE $5.00 for each permit /
❑ SAC CHARGE @ $2230 =
NOTE: WATER METER REl
I hereby apply for a water or
accurate; that the work will be
only an application for a pe '
SIGNATURE OF APPLICA
APPROVED BY:
COPY GIVE O� r
7b3 57z 3ssl
��o ��
TOTAL $
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING
NEW WATER METER COST — SEE UTILITY BILLING
SPECIAL ASSESS1vIENTS — SEE FINANCE
WATER TAP — SEE ENGINEERiNG
'AIR, INSP OR SHLJT-OFF / EVENII�TGS, WEEKENDS & HOLIDAYS $125BOUR-BI]
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
(new co " n or repair) permit and I acknowledge that the information above is complete and
fo � the ordinances and codes of the City of Fridley. I understand this is not a permit but
v o o start without a permit.
PRlNT NAME: __��� �G/. � •'� �-/ /
. .... fi� -�� DATE: �
� DATE: � � Z � J
(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