P - 48371r,�igineering WATER AND SEWER Permit No.:
763-572-3552 PERMIT APPLICATION Received By:
763-571-1287 fax CITY OF FRIDLEY D��,��� 1
EFFECTI V E O 1/O l/2011 �
APPLICATION DATE: (/J "�" � � YOUR E-MAIL/FAX: _
THIS APPL[CANT IS: ❑ OWNER �NTRACTOR - w
JOB ADDRESS: J�Z q �/��'1 PS �/ �/i�
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME:
OWNER/ ADDRESS: CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR ' Na,ME: � d a
SUBMIT A COPY OF ADDRESS: %?� �c t.v-a-L �� GTY STAT ZIPS'S3 So D
YOUR STATE �/
LICENSE WITH PHONE !�� �% �---(o'� /�Z CELL PHONE: �l Z� � Z�Z� ''� 3 S-T�
APPLICATION
STATE L1C # STATE BOND: EXP DATE:
L Narrativ%y.ritten description: ��
�,-� s�- L t,...- .v � / D��� ��r �,Pr.� , r � - �.�- /��. � �
Ah.11 �� �
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page. -
3. Stipulations: � �iL.�� �3�� a�.�' ['�.... �'r z �u2 �•Q.Xtus,e��c�U'n �/ w^�
/ •
i�.,� � ° �{ e 3 . �,..�,.�� ' -� k�.�. '
� � �., � . ` 2 �s ,v� ' ' .
PERMIT TYF �7G 3- Z 3$� 80'i C
� 7� 3- 2 3�? " 8os �
� SEWER CONNECTION PERMIT C SEWERDISCONNECT PERMIT $50 �+R ?6 3' S7Z - 355
❑ WATER CONNECTION PERMIT i; SEWER DISCONNECT PERMIT $50
� WATER LINE REPAIR $40 YO
:�� SEWER LINE REPAIR $40 �
❑ ADD STATE SURCHARGE 55.00 for each permit S
❑ SAC CHARGE @ $2230 =
; ,�.—
- TOTAL $ �S.
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 $l25/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL PROCESSED
I hereby apply for a water or sewer (new connection or repair) permit and I 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 work is ot to start without a permit.
SIGNANRE OF APPLIC PRINT NA � DATE: I
APPROVED BY: DATE: � ��_
COPY GIV T�: ❑ UTILI Y 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
� ��� � � � �� � �� � ������,,� �� �
�
_"_---��
�
�
�
�
�
�
S
�� -�^�-
� � ���
,. �.--
S c `
� �' �
�
1
�
�
�
�
�� �