P - 48360�Engineering � WATER AND SEWER " Permit No.: �
763-572-3552 PERMIT APPLICATION � Received B:
763-571-1287 fax CITY OF FRIDLEY Dat��d:
EFFECTTVE 01 /O l /2011
APPLICATION DATE: ���%'�l� YOUR E-MAIL/FAX: � a J..i.
THIS APPLICANT IS: ❑ OWNER p� ��"CONTR�rACTOR -Z ; �J O C.� 7 a�
JOB ADDRESS: �� y LOLt rell0�v 7� �� � /! 17 �-(. �
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME: aberf- 4�S�C � -
OWNER/ ADDRESS: y��I C�r�fe�lOk- S� �� CITY F�i� � STATEMyZIP
TENANT pHONE: 7 6��- 7f16 � 3�310
CONTRACTOR NAtv1E: �� �� haI �- �
SUBMIT A COPYOF ADDRESS: o?„� %O � p�I� CITY �h PAsc I STATE�ZIP %�
YOUR ST.9TE ^ �-
LICENSE WITH PI�ONE _�S�I '� Y`7 � o`i-�- CELL PHONE:
APPLICATION STATE LIC # G �r7 � �G SigG "' `tG i �% �
STATE BOND: EXP DATE: �
1. Narrativ/e�/written description: � n L /
�-f�•� S`� �'c�Ce,li r7 ��ic Y�awf Sda—p�� f`��ae,�.� 'I°�+�-rt�»'1 f�.c. /�SC.�r.
2. Please attach sketch showing curb line, utility line, building, ef . with distances on back page.
3. Stipulations: GY'�� �'v �"�8 � � �63 z3 � �d 7 �
� , '� ` d ��w� , �, ���r��' ,
;
PERMIT TYPE
� SEWER CONNECTION PERMIT ❑ SEWER DISCONNECT PERMIT $50
❑ WATER CONNECTION PERMIT �-, SEWER DISCONNECT PERMIT $50
� WATER LINE REPAIR $40
� SEWER LINE REPAIR $40 0 �
❑ ADD STATE SURCHARGE $5.00 for each permit
❑ SAC CHARGE @ $2230 =
� TOTAL $ � �
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 MET'ER REPAIR, INSP OR SHIJT-OFF / EVENINGS, WEEKENDS & HOLfDAYS $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL 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 wor 's not to start without a permit.
SIGNATURE OF APPLICANT ����" " PRINT NAME: /G(4�I �C/l� ya.�st S DATE: S��//�I
__ ' ,
APPROVED BY: DATE: S �
COPY GIVEN TO: : uTiL Tv s LING (only if new meter) � PUBLIC WORKS :-� ENGINEERING
City of Fridley ��J
Engineering Department �
6431 University Avenue NE, Fridley, MN 55432 � ��
763-572-3552
FAX: 763-571-1287
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