P - 48439�� Engineering WATER AND SEWER Permit No.: �'�
�?63-572-3552 PERMIT APPLICATION Received By:
763 -571-1287 fax CITY OF FRIDLEY D��,�:����
EFFECTIVE OU01/2011
APPLICATION DATE: �� !� ) � YOUR E-MAIL/FAX:
THIS APPLICANT IS: ❑ OWNER J�CONTRACTOR
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NEW CONSTRUCTION PERMIT# QF APPLICABLE):
PROPERTY NpME: ' l+�-r, /I- , ,n , 1
OWNER/ ADDRESS: �j(.� � n (`� ('� ��� i� - CITY � ; ' � STATE��IP
TENANT pHONE: � ( 2 ' �c^'I % - `� `=� �3 �
CONTRACTOR NAME: �i . 1 �r
SUBMIT A COPY OF � t /� p c"'�-_ J t
YOUR STATE ADDRESS: 2`Z ��I l_Ct,jiw� I�C� • CITY .'!, . 1 C�U 1 STATE�ZIP�`� � I y
LICENSE W/TH PHONE 4�'hI —��eJ D�p2 Z CELL PHONE:
APPLICATION �
STATE LIC# �'�=' ���� �'�" I� ��� STATE BOND: EXP DATE:
1. Narrative/written description:
`;�t,;,:1 z�" ��l�,'�h � �" � i ) �v C� e1 � �� �'`�_� _�'1 � -�-� ,�-- (—�,;,-�
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
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3. Stipulations: ---� e ��� `l�� <�[,v� �� ���. ��� L-C3ti�� ����-
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PEKMI'�I'YPE ��
�: SEWER CONNECTION PERMIT � SEWER DISCONNECT PERMIT $50
!_1 WATER CONNECTION PERMIT ����� SEWER DISCONNECT PERMIT $50
��� WATER LINE REPAIR $40
,�. SEWER LINE REPAIR $40 � -'
L' ADD STATE SURCHARGE $5.00 for each permit �'
❑ SAC CHARGE @ $2230 =
. . � -°.�;
TOTAL $ r
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 NIETER REPAIR, INSP OR SHUT-OFF / EVENINGS, wEExErrDS & HoL�D,avs $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT1L 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 and work"is not start without a permit., I�
SIGNATURE OF APPLICA3Q7'_,--- �- PRINT NAME���',..11-�y�`��6 v H,�..-'�TE: � I�
APPROVED BY: y� DATE: �� i
COPY GIVEN 0: ❑ TILIT BILLING (only if new meter) ❑ PUBLIC WORKS - ENGI EE ING
Lity ot r r�a�ey
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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