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P - 74939
Name: � �'�' CI�TYx OF FRIDLEY WATER AND SEWER CONiVECTION PERMIT APPLICATI'bN Date: ��� yy��Y f y9� �v . � (Home Owner or Plumber) Job Address: ���� �-�-t C_/ A(�-fi r�-��. N� -� nr wm m �r�r rcerT no enn�r�nN LEGAL DESCRIPTION - i . � PERMIT: � SEWER: FEE: °�'3 ' �� ✓ � WATE R : METE R: FEE: �`� " � DEPOSIT: (GC/- UC� 19.�_ � 0-DAPTER: � SU CHA RGE: 5 � SURCHARGE: `�— yJ� TOTAL: °2� `� � TOTAL: �`S S v TOTAL: ��-`�`� � ��v�f� � GRAND TOTAL: �a � � S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: NEW STRUCTURE: BUILDING PERMIT No.: SEWER/WATER PERMIT NO.:�L SPECIAL ASSESSMENTS:.(� y�� Signed: By: