P - 62721Engineeri.n.g WATI�R AND SEWER P�rnit rrg: r� ��
�
��3��72-3552 P�FCMI'T APPLICATION Received'By. ' "� =� �
763�571-1287 fax CITY OF FRIDLEY �ate �ec'd. '�'l �`'1�
� EFFECTIVE 01l12/2012
APPLICATION DATE: 7'�ll �" ��' YOUR E-MAIL/FAX: !' fF ��- ��} d c�� ,( j J.� ,,r4- r l, C o�
THTS APPLICANT IS: O OWNER �ONTRACTOR .
aoB anmt�ss: (o � 3 ! � � Grf;. �t �. S-� �� ..
S .
NEW CONSTRUGTION PERMIT# (IF APPLICABLE): ` r:
PItUPERTY xAME: � a.� Ja� � Yi1 c,,. , v Q
OWNER/ ,o,�Dt�SS: crrY STA'tE Ztp
; TENANT ? / `7' 7
- Pxor�: � 6 3 s 9t
s� con�acTO�
� x�: p r � �.� �. n� (� (�'� t° (., � � � �� f
SUBMIT A COPY OF �DRESS: � Y 2 Y 3� s�-- � CITY n^ y� � S STATE��ff+ S�� /�
YOUR STATE `
LICENSE WITH PHONE • CELL PHONE: C� i�- � E� 7 4`7� ��7 �
>:�
APPLICATION �',
STATE LIC # � 7 2'E' � STATE BOND: EXP DATEi �
L Will work take place in City ROW? Ye ' No If yes, ROW registration is required -- se�� '''tYg .'�
�
2. Provi+d�e'� written/ c�escription of proposed work: rQi-� �� YX �� C�-�:--
� � � "�'T �� 1 / ��Qf^... � 1 / �(. . _
�� V � ��
' 3. Attach plan/sketch showing proposed work with existi urb, utilities, trees, buildings, et�. wi�h t�n��is
4. Circie type of erosion control measures to lx installed to preve ' turbed soils frvm erac�ng:
Silt Fence Bio-rolls Erosion Blanket Sodding Other:
5. Provide minimum of 2 hr notice for inspection { 8 arn - 4:30 p eall in the follo�ving o�rd�r: (763j 5�2-
3552, (763) 572-3556, (763) 238-8058, (7b3) 572-3562 or (763) 572-3551, or (763) 427-1212. '
6. Refer to "Constructio equirements for Water and Sewer Work" on baek of page.
7. Stipulations• �� 6
t f J r�.) / 1 8/ d
-7(03 -Z3 I5-'�foY$ :
PERMIT TYPE
� SEWER CONNECTION PERMTT ❑ SEWER DISCONNECT PERMIT $SQ
0 WATER CONNECTION PERMIT ❑ WATER DISCONNECT PERMIT $50
,j�SEWER LINE REPAIR � WATER LINE REPAIR $40
� ADD STATE SURCHARGE $5.00 for each per�nit
❑ SAC CHARGE (a3 $2365 = ,,,
�
TOTAL S _".�—'
- _ � UTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING
NEW WATER METER CC1ST - SEE UTILITY BILLING �. :
SPECIAL ASSESSMENTS— SEE FINANCE
WATER TAP — SEE ENGINEERING
NOTE: WATER METER REPATR, INSP OR SHUT-OFF / EVENINGS, WEEKENDS & HOLIDAYS $1251I�OIIR $ILLEL)
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSfiD
I hereby apply for a water or sewer permit and I acknowledge that the informatic�n above is complete and acc�; tha�t the wox�c will be in
cornfarmance with the ordinarices and codes of the City of Fridley. I understand this is not a�it but only an a�glic�tic�n �'or a� permit ar�d
'work is not to start without city a val ofthis permit application, unless emergency repair is required. �
-, �',�.�- � � �,��: DA�: �- � -- r z_
SKiNATURE OF APPLICANT PRINT NAME:
APPROYED BY: - DA'i'E: f �_
�dPY CirTV�+ �: � UTIL BILLING (only if new meter) ❑ PUBLIC WORKS ❑ EN�GINEERING
City of Fridley
Engineeritng D�partment
6431 University Avenue NE, Fridley, MN 55432 �.
763-572-3552 ,
- FAX: 763-5'71-1287
�
a
,n , _ .
��3�
�'� � ��C i� �� � �� �
r ��
��
.�
��
�� �
�
� �
0
��
b
� ��
_ � ��
�v
� - ,.,�'
�
r.
� _ � fi �'�
� �� r� �
�� �
L t�
�
lo � �