P - 46951Engineering WATER AND SEWER Permit No.:
763-572-3552 PERMIT APPLICATION Received By:�
763-571-1287 fax CITY OF FRIDLEY
EFFECTIVE Ol/O1/2011 Dat�: �q
I
APPLICATION DATE: �"Z ��� YOUR E-MAIL/FAX: i
THIS APPLICANT IS: ❑ OWN„�,.F$ �CONTRACTOR
JOB ADDRESS: ��1I��� �, /%��L`,
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME:
OWNER/ pDDRESS: CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR NqME: �
SUBMITA COPYOF ADDRESS: G ( � CITY K�I G STATE�/L�ZiP �
YOUR STATE ' ' �y
LICENSE WlTH PHON �• �� 2- CELL PHONE: (olZ - 3 -�"_ 39
APPLICATION
STATE LIC # STATE BOND: EXP DATE:
1. N�ativelwritten descy +'ption: l
iSi'�s��t���" �../do`.F.�C �G �w�t� � /%r�;.��v� f/�.c.--r
/
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations: ✓ � �C%J'�T.�� i C c � � :.� J �„�,�,,...�, �6 � Z3g �`�'
6-L _�e.n�- �63 57z 3SS
763 23� $o5g
7�3 S�z 355�
PERMIT TYPE
❑ SEWER CONNECTION PERMIT S ER DISCONNECT PERMIT $50 �
� WATER CONNECTION PERMIT ATER DISCONNECT PERMIT $50
CJ WATER LINE REPAIR $40
❑ SEWER LINE REPAIR $40
❑ ADD STATE SURCHARGE $5.00 for each permit _�(
❑ SAC CHARGE @ $2230 =
_i
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 SHiJT-OFF / EVETTINGS, WEEKENDS & HOLIDAYS $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L PROCESSED
I hereby apply for a water or sewer (ne connecti repair) permit and I acknowledge that the information above is complete and
accurate; that the work will be in co rmance t th , inances and codes of the City of Fridley. 1 understand this is not a permit but
only an application for a permit yvork ' ot ithout a permit.
� �-.
SIGNATURE OF APPLICANT Gl PRINT NAME: � DATE: . S�2'���
�,; _
APPROVEDBY: .f,. � "-_" DATE: �� Z L/
COPY GI�EN �: ❑ TiLITY BILLING (only if new meter) ❑ PUBLIC WORKS C ENGINEERING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287