P - 36796Engir?:�ering
763-�57�-3552
763-571-1287 fax
APPLICATION DATE: L�-- � ` � �
WATER AND SEWER
PERMIT APPLICATION
CITY OF FRIDLEY ��
EFFEC'TI VE 01 /O V201 I 1�'`'
YOUR GMAIL/FAX: �
l'ermit No.:
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THIS APAUCANT IS: ❑ OWNER j�CONTRACTUR
.IOB ApDRESS: -'Z -3 y ./� .(J P C v�r l_., � r I�
NEW CONSTRUCTION PERMIT#t (IF APPUCABLE): � -
PROPERTY N�ME (r � S,�
OWNER/
TENANT AaDRESS:- 7�� (Yi..P v� � u, y- �,r f� f' CITY
PHONE:
ATE ZIP
CONTRACTOR NqtvtE: � c����(--L.-� 6 C,�
SUBMIT.4 COPYOF AUDRESS:_% %�' ��,,,.,.9� V Yx
YOUR STATE � „ CITY ��{.{n.,.,Q,,,P STATE� zir S5 3�a
L/CENSE WITH PHONE ���'�� b�") �-� CFELL PHONE: �/ 2-2 Sp '- (0'39.�'-
APPL/CATfON
STAi'E LtC # STATE BOND� EXP DATE:
1. Narrative/w itten descriptio�n: / s
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2. Please attach sketch showing curb line, utility line, buit ,ing, etc. with distances on back page.
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3. Stipulations: �•
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SEWER CONNECTION PERMIT I SEWER DISCONNECT PERMIT $50
WATER CONNECTION PERMIT 1 WATER DISCONNECT PERMIT $50
i WATER LINE REPAiR $40 (� •--
� `-� i SEWER LINE REPAIR $40
.6^r Gt",, ADD STATE SURCHARGE $5.00 for each permit S-
I SAC CHARGE @ $2230 =
TOTAL $
1� �
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING
N�W WATER METER COST- SEE UTIL(TY 61LLING
SPECIAL ASSESSMENTS - SEE FINANCE
WATER TAP - SEE ENGINEERING
NOTE; WATER METER REPAIR, INSP OR SHUT-OFF / EVENINGS, WEEKENDS & HOLIDAYS $125/HOUR-BILLED
TH.IS IS AN APPUCATION FQR A PFRMIT-NOT VALID UNT1L PROCESSED
[ hereby apply for a water or sewer (new connection or repair) pennit 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. 1 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 R-r�^ ��� `G�j DP.TE: CJ � �
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APPROVED BY:
DATE:
C�PY �IVEN : II ; UT [TY BILLING (only if new meter) C.I PUBLIC WORKS l: EN�
City of Fridley
� Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
, FAX: 763-571-1287
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