P - 80959E�g�tlee�illg WATER AND SEWER Permit No.: ..
�63-572-3552 PERMIT APPLICA'TIUN Received By:
7b3-571-128% fax CITY OF FRIDLEY �� ��'�� �.-�� �.
EFFECTIVE Ol/12/2012 %' .L—� �, .
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APPLICATION DATE: ``� �L'Z / � YOUR E-MAIL/FAX:
THIS APPLICANT IS: � OWNER T�ONTRACTOR p �-�-�
30B ADDRESS: �� S /�/ i S S� S 5/.11� r� �%� �
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' NEW COMSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME: Z t' �'e �r^ i n� c1'�q / f.° r Z. �
T�`ENAN,�,i, ADDRESS: � G' �c f� i s�, s�,, s T CITY ��.,�, C�, J STATE ZIP �
PHONE:
car��cTOR N,�: n9 ..�,�,�, �. w
St7BMITA COPYOF �DRESS:�7� �' �it�w< � CITY I�i�dti► P �..._. STA ZtP '
� YEJ�UR STATE � QL1 s���,'�'�.% d�� s> �;
LICENSE WITH PHONE����'7 rr �%'i /'L CELL PHONE: rD / 2- 2 S ts - ra 3�'/ �''�
-APPLICATIDN
STATE LIC # STATE BOND: EXP DATE:
,
Ff" 5
1. Will work take place in City ROW? Yes No If yes, ROW registration is required - see Engineeri�a�. "
2. Provide written description of proposed work: �.i s��� ��`,do �� ���. s.�r v, t�.- - c c�. �- �,� ';:
��X � `i-i.e D�� v'- �
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' 3. Attach plan/sketch showing praposed work with existing curb, utilities, trees, buildings, etc_ v�i�t dim�v
4. Circle type of erosion control measures to be installed to prevent disturbed soils from erodittg: - �
Silt Fence Bio-rolls Erosion Blanket Sodding Other:
S. Provide minimum of 2 hr notice for inspection ( 8 am - 4:30 pm) and ca.11 in the following Qrd�r: (7f3� 57�- �
3�52, (763) 572-3556, (763) 238-8058, (7b3) 572-3562 or (763) 572-3551,:or (763) 427-1212.
6. Refer to "Construction Requirements for Water and Sewer Work" on back of page.
�. Stipulations •
PERMIT TYPE
❑ SEWER CONNECTION PERMIT 0 SEWER DISCONNECT PERMIT $50
D WATER CONNECTION PERMIT O ATER DISCONNECT PERMIT $50
� ❑ SEWER L1NE REPAIR �ATER LiNE REPAiR $40
: � ADD STATE SURCHARGE 55.00 for each permit
❑ SAC CHARGE Q $2365 = , ,
T4TAL S ����
� OTHER CHARGES (IF Ai'PLICABLE) PAY TO UTILITY BILLiNG
NEW WATER METER COST — SEE UTILITY BILLING -
SPECIAL ASSESSMENTS — SEE FINANCE
WATER TAP — SEE ENGTNEERiNG
NOTE: WATER METER REPAIR, INSP OR SHUT-OFF / EVENINGS, WEEKENDS & HOLIDAYS 5125/H'Q%T�-$IiLBii, '"
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTtL PROCESSED
I hercby apply for a water or sewer permit and I aclrnowledge that the information above is complete and accurate; th�t t1� wt,�lc wilt ise in
confarmal�ce with the ordinances codes of the City of Fridley. I understand this is not a pernut but +only an apptica�tm'�ot a perrnit artci
- work is not to start witho val o ' application, unless emergency rtpair is required. �
SIClNATURE OF APPLIGA� PR1NT NAly�� f' '✓� �/V (,�I(J l�'� DATE: ,� %/
APPROVED BY: � DATE: 7 �' �� � , � ��--
� � . � � � . � � . .. �. . . . °'' 4
�QP� G N T0: 0 UTILI BILLtNG (only if new meter) ❑ PUBLIC WORKS ❑ ENGINE��NG
City of Fridley
Engineering Department :
b431 University Avenue NE, Fridley, NIN 55432
763-5'72-3552
FAX: 763-571-1287 :
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