P - 48287Engineering WATER AND SEWER Pern,it No.• b
763-572-3552 PERMIT APPLICATION Rec�� . ,
763-571-1287 fax CITY OF FRIDLEY Date Rec'd:
EFFECTIVE 01/Ol/2011
APPLICATION DATE: � Z�!R f� YOUR E-MAIL/FAX:
THIS APPLICANT IS: ❑ OWNER � CONTRACTOR �j
JOB ADDRESS: �. ,� YS�3 �" +�QT,� J`� � ^��
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME: /�¢ G � �
OWNER/ ADDRESS: �%S7.i ��"�.�. sS'{ • N�. CITY STATE �''�/ZIP.,
TENANT pHONE: %(o ,7 �-- .� / ° �l �'' �
CONTRACTOR NAME:_ _ G-t.�.7 �•-H�VC. G1�,o�
SUBMITACOPYOF ADDRESS: ��3� CR.1� �'?-. /u� CITY ✓�:?zryr�� /J STATE��ZIP��L�
YOUR STATE
LICENSE WITH PHONE �"� g I—�%�% CELL PHONE: CO � Z°��'Z� �L 8�-�%
APPLICATION
STATE LIC # S'fATE BOND: EXP DATE:
1. Narratiy,e�written description:
�J �. d' ►^�-Bl�v�.2_ �v�- � �� �-...� i� ! h�a G�i. , .
.
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations: Ui S-Z S1'Gi n � eSS S� f. e� �G�� S cj,�� �' C e�P vt��' '�
��e�heo Cc���ec��ov►s. ��rr,y�ef cow�,p�e'��a� �e��nac�s awc� 6Si-�A-
Sa�eN� iMfaS�d't -�'�r ��ccuu'tcf �uH .
PERMIT TYPE
❑ SEWER CONNECTION PERMiT ❑ SEWER DISCONNECT PERMIT $50
❑ WATER CONNECTION PERMIT ❑ WATER DISCONNECT PERMIT $50
❑ WATER LINE REPAIR $40
0 SEWER LINE REPAIR $40 '
❑ ADD STATE SURCHARGE $5.00 for each permit .-r°j -
❑ SAC CHARGE @ $2230 =
TOTAL $ `rl � f
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING
NEW WATER METER COST — SEE UTTLITY BILLING
SPECIAL ASSESSMENTS — SEE FINANCE
WATER TAP — SEE ENGINEERING
NOTE: WATER MET'ER REPAIR, INSP OR SHIJT-OFF / EVEI�TINGS, WEEKENDS & HOLIDAYS $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby app(y 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. 1 understand this is not a permit but
only an application for a permit and wor4 is not to start without a permit.
SIGNANRE OF APPLICANT � PRINT NAME: �� ���� "� DATE: j2 ��y !�
APPROVED BY: Dp�:
COPY GIVEN TO: ❑ UTiLITY BILLING (oniy if new meter) ❑ PUBLIC WORKS C ENGINEERING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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