P - 48555Engineering WATER AND SEWER Permit No.: zoc�, —L►' Z�
7C3-572-3552 PERMIT APPLICATION Received"By:_�
763-571-1287 fax CITY OF FRIDLEY Date Rec'c�: 3`� -1�» ���.
EFFEC7'IVE 01/12l2012
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APPLICATIdN DATE: YOUR E-MAIL/FAX: �
THTS APPLICANT IS: ❑ OWN �'CO CTOR ( t � �
30B ADDRESS: C�3� � FJ � SC,iY�� �'J� N�
1dEW CONSIRUCTION PERMIT# (IF APPLICABLE):
PROPERTY N,41vtE: i s
OWNER/ ADDRESS: � 3 1�'J.4v�,Q s U► /t L '� h14.: CITY �7 u�. e� �-p � STATE ZCP
TENANT PHOt1E: �(� 3-- 75 5' �� i i 2--
CONTRACT4R N,�: �
SUBMIT A COPY OF �DRESS: �"7? '� Td w.�-. '� �- CITY �'Y,A-� �P G STATE �$IP S�S3 �F �
Y4lIR STATE � �
: LICENSE WITH PHONE�Ti7"� W i(�C"'"Es'� I L., CELL PHONE: � F 2, � S U � rp 3'�i �
APPLICATIDN
STATE LIC # STATE BOND: EXP DATE:
";:t
1. Will work take place in City ROW? Yes � If yes, ROW xegistra:tionf is required � see Engi�e�.
2. Provide wri n descrip��n of proposed work: Q i�� L-- C. � r 8
vn P .P �--- /
3. Atta�ch plan/sketch showing progosed work with is ng curb, tilitie , trees, buildings, etc. wi� c�iame ` -t �
4. Circle type of erosion control measures to be installed to prevent disturbed soils from en�g; .
Silt Fence Bio-rolls Erosion Blanket Sodding Oiher:
5. Provide minimum of 2 hr notice for inspection ( 8 am - 4:30 pm) and ca11 in the following order: (?63) 5`72-
3552, (763) 572-3556, (763) 23$-8058, (763) 572=3562 or (763) 572-3551, or{763} 427-1212. ;�
6. Refer to "Constructian Requirements for Water and Sewer UJork" on ack o page.
7. Stipulations: �%Q.Q
. . . . .9 . . . � . . .
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PERMIT TYPE � .
❑ SEWER CONNECTION PERMIT � SEWER DISCONNECT PERMIT $50
� WATER CONNECTION PERMIT 0 WATER DISCONNECT PERMIT $50 , ._,,�",����T� ��
❑ SEWER LINE REPAIR r� WATER LINE REPAIR $40 �J����
0 ADD STAT� SURCHARGE $5.00 for each permit —��,.,5�?—
❑ SAC CHARGE (a� �2365 =
To�rAL � �'`
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� OTHER CHARGES {IF APPLICABLE) PAY TO UTILITY ATLL
NEW WATER METER COST — SEE UTILITY BILLING
SPECIAL ASSESSMENTS — SEE F1NA1�tCE �
WATER TAP — SEE ENGINEERiNG
NOTE: WATER METER REPAIR,INSP OR SHUT-OFF / EVENINGS, WEEKENDS & HOLIDAYS $1251�G�.IRr��LL�D .
THIS IS AN Ai'PLICATION FOR A PERMIT-NOT VAL1D UNTIL PROCESSED
' I hereby apply for a water or sewer permit and I acknowledge that the information above is camplete and accurate; that E�e �vtsrk �vil� � u�
canformance with the ordinances and codes of tha City of Fridley. I understand this is not a perniix but only an applicatit�n f�r � pe�i� attt� ,E
'' work is not to start without city a val of ' pe it application, unless mergency repair is reqaired. �
SIC�NATURE OF APPLICANT b�, FRINT NAM �� %�-' DATE: ��7 I�-
APPROVED BY: � DATE: � �"'�
`�OPY GIVEN T. 0 U ILITY BILLING (only if new meter) D PUBLIC WORKS ❑ ENGII'�EE G
City of Fridley ,
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Eogineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552 .
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FAX: 763-571-1287
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