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P - 41810Engir�eering WATER AND SEWER Permit No.: '(� �I �� 753-572-3552 PERMIT APPLICATION Received By: 763-571-1287 fax CITY OF FRIDLEY D��,� 4�1 EFFECTIVE 01/01201I APPLICATION DATE: � ��7 ^ / � YOUR E-MAIL/FAX: THIS APPLICANT IS: ❑ OWNER �� CON�TRACTOR .IOB ADDRESS: _�� S��% SS/�Dy,p� ,j � NEW CONSTRUC'TION PERMIT#1 (IF APPLICABLE): PROPERTY NAME: OWNER/ ADDRESS: CITY STATE ZIP TENANT PHONE: COI�TTRACTOR NAME: � � S %�L� G`� SUBMIT A COPY OF �DRES � CITY �I �� STATFSN�YZIPS� �8 YOUR STATE — LICENSE WITH PHONE "'�'- �� CELL PHONE: ,� I�?S�9 ��'r,i..� �lJ„ APPLICAT/ON T �°� STATE LIC #1 STATE BOND: EXP DATE: 1. Narrat�ve/written descri tion• ' ,� �ss�a�h£c7P �.tl,4T�� 7` �'�c�J �2 :AT �/?oP�2rY' /� � � � 2. Please attach sketch showing curb [ine, utility line, building, etc. wifh distances on back page. 3. Stipulations: • ,,Q uw � ' � � • -�-c7 w=�'i�--- .y►��.D , �f . C_�...�-2 � ��e�� — 2 �2 ��ncE ,� � � PERM IT TYPE � I' SEWER CONNECTCON PERMiT I SEWER DISCONNECT PERMiT `v $50 � I. WATER CONNECTION PERMIT I WATER DISCONNECT PERMIT v$50 I WATER LINE REPAIR $40 I SEWER LINE REPAIR $40 I ADD STATE SURCHARGE $5.00 for each permit I SAC CHARGE @ $2230 = aD TOTAL $ l ` � OTHER CHARGES ((F APPLICABLE) PAY TO UTTLITY BILLING NEW WATER METER COST — SEE UTILITY BILLING SPEC[AL 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 VAL1D 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 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 work is not to start without a permit. SIGNATURE OF APPLIC _ PRINT NAME: ��SN `�`��Y DATE: � ^°? / �/ � APPROVED BY: DATE: a� l� COPY T:.: UTILITY BILLING (only if new meter) Ci PUBLIC WORKS l� ENGINEERING City of Fridley Engineering Department 6431 University Avenue NE, Fridley, MN 55432 763-572-3552 FAX: 763-571-1287 '-�-�.. . ! __ _ _ _ __ ___ ___ _ __ , __ ____ __---_ ___.__._- _ __.._. . __;� __.__ _ ___ ___ ___ ___ . _--__. _._ � 4' , _ . _ _ ._--- - .. __. _. � _ _ - - __ . _...---- _-- __._ .._ -___ _ � _ _-- _ ._._._ _.____ __. _ ____ ___ __ .___..__ �� ,, ,,, -- _ _ ____ �+ - --_ __..___ . _.-- -_ _ _ _. -- _ ._.-- --_ __ _____._ _._._. __. _.._. _-__. _ _--_ _ _ _ ._..__-- ---_-- ------- - ila _ -----__ _!..� _--___ .._ .___ _/_�-� _�, _ ____ ___.__ _____ ___ ---- ___ _ _.___- --_._ ----__ __--------- , _ �; ' �! __. _ ----- ----.. _.._____._ __ _ _ , __ _ _ __ .__ _____ ___ _ _ -- - -- _,__- - _. ,' 1 __ ---_.._ _;.ti . __ ---- --_ _____ _ _-- -_ _. __ -- __ � 0 4 _ _ _. __ � .— � _.� ..��.5 . _ _____�_�_ _ ;� . � �. � � • �..� I __ _ . . . _.__ __. ._ _. _.;s __-- - --_.__ __ _. .. __._ --- -_._._ ____ _ _ _ _ _ : _�____ �_ __ _ _._.__ ------_ --- _.._-----s.,,�- -- __ _ _ ' � � c� ' � 7/3 �/ t� � ___ _.-" i _ -- --- � - _.._._ __ -------._- �-r--_.. __ . ___ _ __. _--_. _ ____- - __ _ __ . __---. _._. _ _--- - __ �,-- - '�� , I .. ,. ;,j _..___ __ _._ . . . _ _ _ ._... _ __ _ _ _ _ _ _._.._ _.___ __ __..-- ------ _.. ---- _-- - - . . .._. --- -. �._ _: _ _ -U� . ;�) �� .r _ �r� __ _�_.__ _ __ ___ _-'_ __.._ _..----_ -.-- .. _ - --- ---------� __. ____._ _.. -_ _. ___.___ _.. ____----- �;�,, �i ______ __ ___.: __ --_ _._ _ __ .__.._ _ _ ------ _..---_ _------ -, _ _ __ _ . -- _ __ __ � � I -�'' -- � � ,. � � , _. _ _ . r, __ . . _ _. _ _ ___. __ , ;� ,� __--- . _ _ _ ___ _ _ _ _ _ _ ___ . . . ____ . _ _ _ _ _ __ _ __ __._ ___ j� ___ �`I � _...____ _. _--_ __ _....--.._..._. _ _ ; _--- __ .___ _. ______ _ — - _ _ � � _ 3�°� �� -� � �,;,�. .____ __-__ - ---_ --� ._ _ _ __ _. _ __. _ __ _ ___ _ _ _ -- � , r __ --- _ _ � .. . ,� �, �;� �� 3 �,��_� � _ _ _ . . . _ __� , � _ s �� Q� �► o-.� s. _ (�- - - - ----._ _ _____� ; _ _ ,.�� _ ._ �, _. __ . . _ _ __ _ __. _. __ _ } ----_ _ __ . __ , ,, �, � � �,�; � _ ---- � ,_, .. -- - _ - - _--- _--_-- -- r. ---___ ___-- _ _ _ � �I��v�°3 � __ ,, _, W � � _ �+ � _ __. _- ---- -- , ___ ___- � _ _. �.} _ _ _____ _ _ _ _- - -- - � � __ __. __ _ xo �� Q S -v. _ � -, � � S1 � �M � 3�b� , � . �-... � �� . � ��d�c�✓ _ ?/3�z�b � _ _ _ . __ _ ( ��l..:z�__� � _.__ ___ __ _--_ �:_..�,, ,, _ _ _---- - _ . _ - - -- _____ .. _ --__ __ �� _R-vo�, __ _ o�-� � - - _ __ _._ __ - - ___ _ �� _ _._ __ - _ __ . __ __ _ . ___ __. __ _ __ _ . _ _----�- -- . __ __ _ .- ____ ___ _ _ �___ ___._�o�, d�� _ _ _ p� ;, ��, � ____ _, __ _ _ _ _ _: __� _ _.___� _ _ __ _ _ __ _ _ __ _ , __ _ � � __._ __ _ _-- ___ -_ _ __ _ _ __-- __-_ ___. __.. -- ,, ___ _ ___._, _ __ __ _ _ _ _ �, � -- ._.____ __ _. .__ _. __ __. .__. _ _ __ _ _ . ___ , ,; _ __ _ � __ _ _ _ __ _ ___ _ _ _ _ _ - __-__ _ _ _ _ _ _ _----_ __ __ ;� _ _ _ __ . . �7 b�..� 1,� 3 � � _ _ __ _ _ _ _ ____ _. _ ___ _--- _ _____ _ _ _ _ _ ____ __ _ _____ _. _