P - 46950Engineering
763-572-3552
763-571-1287 fax
APPLICATION DATE:'S "2 ^ % /
THIS APPLICANT IS: �C OV✓NER
JOB ADDRESS: �
NEW CONSTRUCTION PERMIT# (IF A
PROPERTY NAME:
OWNER/ —
WATER AND SEWER
PERMIT APPLICATION
CITY OF FRIDLEY
EFFECTIVE 01701/2011
YOUR E-MAIL/F
�
TENANT ADDRESS: CITY.
CONTRACTOR
SUBMlT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
1.
ADDRESS:_�C�D %(Z[�JGL�s l �G. /U G • CITY �'�I�L
PHONE � I?-%��(.NGZ-- CELL PHONE��Z `"3iw3''
TE LIC
2. Please attach sketch showing
3. Stipulations:
BOND:
Permit N
Received By:
line, utility line, building, etc. with distances on back page.
�J 5 , - _ ��-�.�Q..c����c �
763 -z38-$�sa ��>
��3 S�Z �SS� ���
PERMIT TYPE
0 SEWER CONNECTION PERMIT SEWER DISCONNECT PERMIT $50 �(l
� WATER CONNECTION PERMIT WATER DISCONNECT PERMIT $50
WATER LINE REPAIR $40 '
❑ SEWER LINE REPAIR $40
I_, ADD STATE SURCHARGE $5.00 for each permit , f
0 SAC CHARGE @ $2230 =
'ATE ZIP
TE �I�(�,iP��C//
�6 3 _
11
8`8�4�$ �r�
Z�35S/ 4',
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 SHLJT-OFF / EVENI1�iGS, WEEKENDS & HOLIDAYS $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a water or sewer (ne conn on o repair) permit and I acknowledge that the information above is complete and
accurate; that the work will be in con it ordinances and codes of the City of Fridley. I understand this is not a permit but
only an application for a permit a w � o without a permit. ,�
SIGNATURE OF APPLICANT PRINT NAME: /� DATE: �' Z'� f�
APPROVED BY: � DATE: ��r � I
COPY GI T:❑ UT ITY 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