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P - 37478En�ineering WATER AND SEWER Permit No.: bt 7�3-572-3552 PER�T APPLICATION Re ' B�� ,, � �ITY 4F FRIDLEY �' � � ` 763-571-1287 fax EFFECTIVEQ1/01CLOli D �"�: APPLICATIQtv DA'['E: I " �I - aZall � _ YOURE-MAILlFAX: CY��/ �I� f�2-�Il/� (�i t5d��%1LalSf' _ /I�fi� _ ifi1S APPLICANT IS: ❑ OWNER i� CONTRAC7'OEt .ros�vxFSS: 3�l .S2o.��,n Sf 1fi+�' � :'�/� /Ll�/ �<S`�132— l7�{0 NEW CONSTRIJC'CION PERMFT� (IF APPLICABi,�}: PROPERTY NAivfE: �/�� '� Ow'NEw Apn�ss:,J27oS F4L+.nkc�-/Akc. e?� ta,;�-cr� A�a%aYt1� STATE��vZ[P 'F'EIYANT PHONE: 7�03 —.=i G 7- 9 3�� CONTRACTUR NAME: ,L7/ir/�s !'�oh S-,Lltw�f�on SzOVrGe�iS �NG � SUBYOURSTATEOF ADDRESS:I�70o [TG.n�A, {ti /2_�� D/Z-�u� CITY 2A�*6L� STATE��ZIP�,�',3Q.� LICEI�SE WITH PHONE J�3 - �2Z � ° C ytJ CELL PHONE: G � ' � �l - � �� pL,rcArrv�v S7ATE LIC # Q! �/ sTa� sonm: � 0 99� s EXP AATE: �- f- 20lZ l. Narrativelwriften description: �iar� � i�G�6{,� SPRu�cc. fitc�n N�x,� � G.� �e.¢-0r�� aw�- �'S� F�a-P 2. Plesse attach skctch showing cnrb tine, utiiity 6ne, bnildiag, etc. witti distances on back page. 3. Stjpulations• �i°ar� Z-�' �'1�S �I�,C0.0 ��.!' ��nS�eC�Jv� � i�(_5�� _ �fV` �iGl°.k1� �l �v�� y►��c�ctl�:� yt��t�toelS. �'o�►�.eet�`�y� S w�u5r b� ��nspee�er.� -�v� �ec��cn�f ge�� c��c'r'^� . � PERMIT TYPE � SE5]�'ER CONNECTION PERMIT ❑ SEWER D[SCONNECT PERMIT S54 tJ�� C�oo:+9i,t�-�6n P��1.Y►�'}' )Q WATER CONNECT[4N P�RMIT II SEWER DISCONNECI' PERMIT S50 _� C6 �U �i � WATER LIN� REPAIR � ❑ SEWER LINE REPAIR � ' k� ADD 3TATE SURCHABGE 55.00 %r each permit A`'�. o0 ❑ SAC CFiARGE (a� $2230 = TOTAL S � SS.� a� OTHER CHARGES (IF APPLICABLE) PAY TO UTIIdTY BILGING NEW WATER METER COST — SEE UTII.ITY BIL.LING SFECIAL ASSESSMENTS — SEE FINANCE WATER TAF — SEE ENGINEERING NOTE: WATER METER REP iNSP OR SHUT-0EF ! EVEMNGS wESx�DS a� xoi..tDA�rs $125/HOUR-BILLED THLS IS AN APPi.[CATION FOR A PERM17-NOT VAL[D UNTiL PR�CESSED 1 hereby apply for a water ar sewer {new connectian or repair) permit and I acknowledge that the information above is cojnplete and accurate; that the work will !ae in confa�mance with the ordinances and codes of the City of Fridley. I understand this is not a permit but only an applicaRion for a pernnit an woric is not to start without a pertnit. SIGNATIIRE OF APPLI �j%" ` PRINf NAME: �� v"��""'� DATE: I��/ � "' .M... APPROVEDBY: -� DA"[E: C4PY GIY�+ 1Y� TU: ❑ uZ'[�.�� s��t� (o��y �t n�w rneter) ❑ pus�[c woRxs C ENGINE�RING ' City of Fridley Engineering Depsrtment b431 University Avenue NE, Fridley, MN 55432 7b3-572-3552 FAX: 763-57 i -1287 L'd �L06-ZZ�-Z9L ae��eM e�(�y d66�Z6 66 90 u�f , ' � f 2i � �� f' �e � / ` �'Y Li"f' } c+ Y1 �� GAtLAG � �f�On�'"J'i S��ctr'�' b � �' � C � �.s s�� v1'vr..S �✓✓G � � � 38� �',�� Sf �,� f�o�.sz �� •r � % Z� � . 1� �� .� - �o .Q � � Z'd tiL06-ZZtr-Z9L aeiienn E�w d6L�ZL l6 90 ��r