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P - 40014Feb 08 2011 1z:37PM HP LASERJET FRX 651?62�500 p.l 'Eriglileering WATER AN'b SEWER 1�ermit No.: ��f �° ,. 7�3�572-3552 PERMIT APPY.ICATIQN Received By: 7b3-5 71-1287 faz� CITY OF FRIDLEX aFFecT��so�rotnoii �'� � °` � � � y AE'PLICATION DATE: �`_ P�� Y�LiR 6,MAYIJFAX; I�1 �i. LC�.�`a .� �i�►L4�'*�. c a+1. (r S l� �� + TH]S APPLiCANT IS: O OWNER �COIVTRACTOR / �/ `l y��s• 70B ADDRESS: I S7 � s���fi r�? St /1% � � �D�I Z� D' D��/ � NBW CON3TRUCTTdN PERMlT# ([F APPLIC:ABLE): PROPERTY NAMFi: .� c. C.�.+� OV4'NER/ App�sg, CI^l',_ . 57ATE TENANT --Z�P— PHQNE; CONTAACTOR NAME: Iya �`s • ` •t � t SUBMIT A G`DPY OF ADDRES3: r� � 7� L��[ _� YOURSTATE f�--�'�' CITY '� �� L�Jr STATEI!'►��IP ����� LICENSE If�ITH PHCINE ��/� �' b��� S�' ;° CELL PH4NE: LS� �' aL +'� ` 3 L°'d APPI.ICATlON STACBLIC# �`g�ay STATEBpN,i,); �%����= EXPDATH: ��'�r�`� 1. Narrativ�written descripttaa: /' , �� f w 1� l�a✓a'c r � d r v'tr �� ��. L� e��.� e l� r w� .-.-„ Z. Please attach sketch shmving curb ifne, utllity Ifue, building, ete� with diatances on baek psge. . a. st�put�nan�� I s�r �v��vF,c.�r�u.,� Tc� vPPF� S�i.c r3� l�'/� �� ��o�f�s��a� 2. o�i+� ��c.. �,�c,c�4��-r��.�, 3. c�LL �-�s ��'L.IOQ._ �ro lNSPEC-T�C�N ot eo.✓�v�,,7,GwS — QaN'T j�lLY �NliL /�ol�'E.D. �f ���n9�C-7" /N DAIE �T` LlFTS. �Pl.✓�c� IJA�Ae�E/� C�vPF�(L- Pl E PER.t�I�' i"YrT i'� SEWER CONNECTION pLRMIT � � SEWER DISCON�I�CT FERMIT S50 ':1 WATER GONNECT'ION PERMIT ;. i SEWER DISCO�i�iE�T P�RM1T S50 �WATY3EZ LINE REFAIiZ $40 � u s�w�t �.rrr� �am s4a f.t ,+�,bD STAT� SURCHARGE 55.00 for each permit , � SAC C�TARCiE � $2230 = TC!'�'AL � � `7 � � OTHER CAARGES (YF APPLICAHLEa PAY TQ UTILITY BILLING NEW WA,TTR 1�iETER COS T— SLE 'UT[LITY BILLING SPECIA�, ASS$SSMEr�['S — 5EE FII+dAhfCE WATER TAP — $F,� �2,iQTNEERpVQ NpTE: W1#7'�R MET�R REFA INSP QR SHUT-OFF ! EVEI�TNGS w�rpc�DS a� HQl.ranYS $125lHOUR-BILL�p THl9 I5 AN APPLICATlON FOR A PERMIT-NQ7 �AL1D UN'I'1L PR�C&SSED I hereby apply for a water or sewtr (newv eonncetion or repair) permit snd I aclrnowledge that tha infarmatian above is compiete end accurate; thst ihe work witl be in eonformance with the ordinanebs and cQdes of the City of Fridley. I understand this is not a permit but only an, application for a permit and work is not to atart withaut a permit. 9IGi�:1TURE OF APPLICANT PtiIN7 MAMB; _ �°�° ��� � _ DATE� � � p � � APPROVBUAY; �6 J`�%Z' ,✓J`�J`�� DATE: Z' g��� �Q�X G��� ; r UTIL TY BII.LING onl ifnew meter "1 PUBLIC WORiCS ` ENGINEERING Cxty of Fridley Engineering riepartment 6431 Univer�ity Avenue NE, Fridley, MN' S543� 763-572-3552 FAX: ?53-571-1287 Fe� 08 2011 12:37PM . t t k, ��� �� HP LRSERJET FRX 65176�25�0 p.2 ,�„ �(�.�r..�r �'l�,�M � .e� ec ,,,5 � T - 7 - - � �v�' � dr L'� �� li� � z��"� � ,r R� ' ��� � � �� � � � � � On� Co�' �(,%`� �� �