P - 40222Engineering WATER AND SEWER Permit No.: ?.� ��
763-572-3552 PERMIT APPLICATION Received By!`���9
763-571-1287 fax CITY OF FRIDLEY _ ���
EFFECTIVE01/0112Ull Da�' '
APPLICATION DATE: �// �' �// YOUR E-MAtUFAX: _
THIS APPLICANT IS: ❑ OWNER f�CONTRACTOR
.IOB ADDRESS: � / �% �r � yi �C1 � �i , /k � ,
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME: C.�''% r��=5 � � i S�—.
To NANT ADDRESS: �!'`�Yl `�--.— CITY STATE ZfP
PHONE:
CONTRACTOR NAME: �,�,r� N
SUBMITA COPYOF +-�.�
YOUR STATE ADDRESS: �/.�"' %3 ��`t i�'1 CIT t? � STAT� ZIP SS3 �/�
LICENSE WITH PHONE%� 3��7� —Gy 7/ 'Z CELL PHONE: �4 � t- - 2�.s �. 6�5'J`
APPLICAT/ON
STATE LIC #! STATE BOND: EXP DATE:
1. Narrative/written description• p� �s
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2. Please attach sketch showing curb line, atility line, building, etc. with distances on back page.
3. Stiputafions: (_%C�.� -
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PERMIT TYPE 572— 375�
I' SEWER CONNECTION PERMIT I SEWER DISCONNECT PERMIT $50 �� Z'�3�5 1
L WATER CONNECTION PERMIT I WATER D[SCONNECT PERMIT $50
WATER LINE REPAIR $40 —�'
I EWER L[NE REPAIR $40
I ADD TATE SURCHARCE $5.00 for each permit
I SAC CHARGE @ $2230 =
TOTAL $ � � � �J
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 $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VALlD UNTIL PROCESSED
I hereby apply for a water or sewer (new connection or repair) permit and 1 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 �d work is ot to art without a perrnit.
S(GNATURE OF APPLI ANT PRINT NA /.�y��/' �����'� � DATE: I
APPROVED BY: DATE: L /
COPY GIVE : r; Ti Y BILLING (only if new meter) Ct PUBLIC WORKS l� ENGI EER G
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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