P - 36948Engineering WATER AND SEWER Permit No.:
763-572-3552 PERMIT APPLICATION Received By'��
763-571-1287 f1X CITY OF FRIDLEY Dat�d•
EFFECTIVE dl/Ol/2011 �
APPLICATION DATE: � / YOUR E-MAIL/FAX:
THIS APPLICANT IS: ❑ O ER CONTRACTOR
lOB ADDRESS: �'�� � L/�1,�r �^7� S�
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME:
OWNER/ ADDRESS: CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR NAME: -� c T�' �C cc�2v
SUBMITACOPYOF ADDRESS: Fi�c, GULl�/�' G�U� �// CITY %%/✓�S STATE�tiZIP�/
YOUR STATE
LICENSE WITH PHON T Y ' Z CELL PHONE: G/Z .?jG i? �i' Z�/ �
APPLICATION STATE LIC # G S SS�t ��"� STATE BOND: EXP DATE: !2 ' `
1. Narray'�y e/written description: ,,
7✓d<SGa�l�r�-�LT �di/�C/ b�' S'eu�-e � �'i T�/'o�i�7'�' �j�st/� �
2. Please attach sketch showing curb line, utility ine, buil ing, etc. ith distances on back page.
3. Sti ulations: 1�.�/r ��� �
P
;
PERMIT TYPE
���r ��
❑ SEWER CONNECTION PERMIT � WER DISCONNECT PERMIT $50
❑ WATER CONNECTION PERMIT��R DISCONNECT PERMIT $50
WA'T'ER L1NE REPAIR $40
� SEWER LINE REPAIR $40
L ADD STATE SURCHARGE $5.00 for each permit � �
❑ SAC CHARGE @ $2230 =
TOTAL $
V
OTHER CHARGES (IF A�PLICABLE) PAY TO UTILITY BILGING
NEW WATER METER COST — SEE UTILITY BILLING �
SPECIAL ASSESSMENTS — SEE FINANCE
WATER TAP — SEE ENGINEERING
NOTE: WATER METER REPAIR, II�SP OR SHUT-OFF / EVENINGS, WEEKENDS & HOLIDAYS $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LJNTIL 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 i onformance with the ordinances and codes of the City of Fridley. I understand this is not a permit but
only an application for a pe a d r is not to start without a permit.
SIGNATURE OF APPLICANT �^ PRINT NAME: G� ���✓ � / r DATE: �� '/
_.__ / /
AePPROVED BY DATE: � v /
COPY .� u ILITY BILLING (only if new meter) ❑ PUBLIC WORKS .�� ENGINEERING
��ry oi rr�a�iey
Engineering Department
6431 University Avenue NE, Fridley, MN 55432 n Q�
763-572-3552 � l�
FAX: 763-571-1287