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P - 74953� Job Address: CITY OF FRIDLEY WATER AND SEWER CONNECTION PERMIT APPLICATION � t'�-e-t � > > � � �� (Home ner or P mber) / �C� ��J�f�l LEGAL DESCRIPTION � a7� Date: �v �� 19L,.� � _ /- /� j� .rC��.lJ �� K TRACT AD ITION �� _��'�� f�d� PERMIT: � SEWER: WATER: METER: FEE: FEE: / '�� DEP061T: O-DAPTER: STATE STATE � � SURCHARGE: SURCHARGE: TOTAL: ''�OTA�: /� � TOTAL: ;_i � ! - GRAND TOTAL: / ��`� _ S.A.C. CHARGE ON EXISTING �UCTURE: EXISTING STRUCTURE: NEW STRUCTURE: BUIIDING PERMIT No.: SEWER/W�\TER R�RAAjT, NO.: �� A SPECIAL ASSESSMENTS: Sign �� . �--� r `� � X�-r � � 1 7 ��'' � %' � } 8,,: �� ,�vN � �� i