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P - 44596ZD10 Oct 26 16:28 63-5?2-3552 b3-37�-1287 fax HOVAFROST FRX e wATER AND SEwER PERMiT APPLICATI4N CiT"Sr OF FRIDLEY EFF6C71VE 711f2010 PUCAT(ON DATE: D'a.� � YOUR E-MAIUPAX:� fS APPL[C/WI iS: OWMER O1N�TRACfOR 3 ADDR8S5• �% %-7 C l�.��, c�� ti S ov- S�` ► w CONS'rRUCrtoTl pFRbtrn (� �LtCABLE): p�rorES�rv � u t �. r�r �, . owx�v Ann��.s• '?G7S �-tA,G&.��:� � �: c �Hwnrr raax�: �ONFItA(.'TOR �w�:_��,t *. f(1c :t'' ��.�.- T��rlT,c (aOPYOF ,wn�eESS:�3�'7 f�w,,�w�,rc.s.- Or P06ak� YOiVII'SiAf7B �.rct�sB wlTf�' rr;orrE _CQSt"-�gD-. � 4-�f � c��.r. rxo�: .lPtLIGl7oN sra� vc �r S4 G�e �i Z.S" �.,r ��.,,,. 6514808527 p•� C�i�lt 11�.. �.� • : � D������ d � , , � iYl.a ��f:'t-\}�I �..l���: _. ..f . �3. 31 � 20 � � 1. Narratirdwrittan dese�t�oa: .�.pt�',b� +t3 S!o! ,?9 7 P�? —�r�ir �1ilt�•�,'� b���IL j YM'ci�C•r. 4dfi �.. � Qc� ILr.-�t �oy` ,4�1 !�1 sZ��O,.i,"� ��_,_ 2• Pls�se:ttaeh eketc6 showing curb Ilne, atitity Nns, bu�ding, etc. w�ith dhtsnoes on bnsk p�ga s. sa���: - f► �'�l.Q c,� i Z�i- �-S N��'"l CL Fc7�- INSPF;C7ioxJ - Z- �S 2. �s-Q- � p��.� ' • . . �-- C�c.{ �,�,.t� �� ��ce�,c,�, r,Q,au,r,. .�� � fu.�:�,d � ��s �:, -- �� W�R CONNE�CT[ON PERMYT SSp ,�d ,� � A'!'ER CONNECTION PbRMIT �Sd '�� . D�'� 0 VifA'fER L1NE REPAIR � D SSWER LINE REPA[R �40 a ADD STA'� StFRCHARG� SS.qo O SAC CHAR.l3B (a3 52100 � 1�UTAL S ��D�� � vz��R CtiAliGLS �iR APPLICwBLE) PAY TO [7TILiTY BILLING �• � NEW WAT�R ME'['ER COST- 3PE UTlL,STY BU,�.iNa ��`` f SPECIAL ASSESSMENT� - SEE FINANCE , WATER TAP - SEE ENGINE�R�'NCf N07"E: WATER NIETER REPAIR,INSP OR SHUT OFF / EVENINGS, wE�cp�n3 a yOUpqYS 5125/HQUR-BILLED Ii{39 !3 AN APP�.iCAT�N FOR A P£Rh�RT•NOT YALLD UN77L P'ROCESSED � sPp�Y �or a wacer a sewer (new aynnxtion or npair) Ppmit end 1 adu�owledg� that the ic►focmatian above is ccnnpleoe and ��dut d�e wark will be in confeacnu�ce w' tha �dims�aces and c�d� of � City of �ri¢ley. I unde�and this is not a perrnft but applkaition i�br a pa�mit is t without a pe�rni� StQNA'!'t7REOFAPPLtCM1T - AWTNAMB: /G/l�'f /`^� I/ DA'!'E�: � OY6d HY: DATE: � [ %O PY G . 0 tLtTY BII,LDVG ont it4ew meter n PUBL�C WaRKS [ BNG �R[N�G City of Fridfey Engineering Department 6431 UnivGrsity Avem�e NE, Fridley, MN 55432 763-572-3552 FAX: 763-571-22$7 � • T'd 6it,6-ZSS-S9G Q�al ZixH dEi=?O Oi 8� �a0