P - 36046Engineering WATER AND SEWER Permit No.: (
7�3-572-3552 PERMIT APPLICATION Receiv
763-571-1287 fax CITY OF FRIDLEY ��I�����
EFFECTIVE Ol/OU20t 1 ec d:
APPL[CATION DATE: �' � � / / YOUR E-MAIL/FAX:
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
.IOB ADDRESS: --2 -3 � � .Q f� C l�r C., � ,r j� � �
NEW CONSTRUCTION PERMIT# QF APPLICABLE);
PROPERTY NAME: C.- .S
OWNER/ ADDRESS: (�(�IVPV' � c-�.v' S� r"I� f' C[TY Lv STATE Z[P
TENANT
PHONE:
CONTRACTOR NqME: C
SUBMIT A COPY OF ADDRESS: �% � S� v.r�'7 CITY [� STATE� ZIP �S � i6d
YOUR STATE � �QV�-��
LlCENSE WITH PHONE��j��'�� }j7 I'L_ CELL PHONE: 6/ 2-2 S'o � G?,`t',�'-
APPLlCATION
STATE C.IC # STATE BOND: EXP DATE:
1; Narrative/w itten description: t
° ��� � ��%� Cil� �� p h P
2. Piease attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations: � ( 2
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C' SEWER CONNECTiON PERMIT l SEWER DISCONNECT PERMIT $50
I.; WATER CONNECTION PERMIT I WATER DISCONNECT PERMIT $50
! WATER LINE REPAIR $40 (� '"
I SEWER LINE REPAIR $40
I; ADD STATE SURCHARGE $5.00 for each permit �
I SAC CHARGE @ $2230 =
t..�� I
TOTAL $ 1 �
OTHER CHARGES (fF 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, WEEKENDS & HOLIDAYS $125/HOUR-BILLED
THIS IS AN APPUCATION fOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply 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 co formance with the ordinances and codes of the City of Fridley. I understand this is not a permit but
only an application for a ermit work i not t start without a permit
SIGNATURE OF APPL ANT PRINT NA Y/`y /� C� `�' `7 DATE: �� /
APPROVED BY: DATE:
COPY GIVEN : r, UT ITY BILLING (only if new meter) C� PUBLIC WORKS l:' ENGI E ING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287