P - 48418Engineering WATER AND SEWER Permit No.: Z d�l L GG �u �
763-572-3552 PERMIT APPLICATION Received By:�`�� ,� ,
763-571-1287 fax CITY OF FRIDLEY , �� ��, .�_L'�'"
EFFECTIVE O1/12/2012 Da C� � `.,'
APPLICATION DATE: r� "' pZ,� —�p I�i YOUR E-MAIL/FAX: �Cv7�_S C� h/_��/ P��,� r��--� � . C���--L.
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR 3 r" '�1Gh"�-G. _�s l
JOB ADDRESS: � � �v � /�E . � n ;S �, /�� �--
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME: f'o � c.1 �,,�✓-
OWNER/ pDDRESS: y L„ ��, A �,.. CITY c� C' �� STATF�i ZIP d
TENANT pHONE: 7(�+� � v� � t'?� S S��� � �y� �
CONTRACTOR N�tE: ,'1 �� ' �� ) - ,� C,.- d �{- L
SUBMIT A COPY OF �DRESS: � J?�,1 �-,-� CITY i� �, STATFyvti/l Z[P .S'���� >
YDUR ST,9TE
LICENSE WITH PHONE � d� -- S'LY� �(� G�/ � CELL PHONE: -3�c� -`j v- � j� (o G
APPLICATION
STATE LIC # r' I" %� STATE BOND: k1 I��¢. sc'v1I- EXP DATE: �` -�"= �_�
1. Will work take place in City ROW? � No If yes, ROW registration is required — see Engineering.
2. Provide written description of proposed work: t r� � l� I� ��� i,n S c,..— °�
3. Attach plan/sketch showing proposed work with existing curb, utilities, trees, buildings, etc. with dimensions.
4. Circle type of erosion control measures to be installed to prevent disturbed soils from eroding:
Silt Fence Bio-rolls Erosion Blanket Sodding Other:
5. Provide minimum of 2 hr notice for inspection ( 8 am — 4:30 pm) and call in the following order: (763) 572-
3552, (763) 572-3556, (763) 238-8058, (763) 572-3562 or (763) 572-3551, or (763) 427-1212. '
6. Refer to "Construction Requirements for Water and Sewer Work" on back of page.
7. Stipulations:
PERMIT TYPE
� SEWER CONNECTION PERMIT ❑ SEWER DISCONNECT PERMIT $50
❑ WATER CONNECTION PERMIT ❑ WATER DISCONNECT PERMIT $50
f�SEWER LINE REPAIR ❑ WATER LINE REPAIR $40 �-j (�
❑ ADD STATE SURCHARGE $5.00 for each permit 5
❑ SAC CHARGE @ $2365 =
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 METER REPAIR, INSP OR SHUT-OFF /(EVENINGS, wEErcErrDS & Hot,iDaYS ) $125/HOUR-BILLED
THIS [S AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a water or sewer 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
work is not to start without c' approval of this permit application, unless emergency repair is required.
SIGNATURE OF APPLICANT , PRINT NAME: ✓(' p' ��`� DATE:
APPROVED BY: 1 DATE: 2^� Z'� Z
COPY GIVEN TO: ❑ UT LITY BILLING (only if new meter) ❑ PUBLIC WORKS ❑ ENGINEERING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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