P - 48518Engineering " WATER AND SEWER Permit No.: 2� �
763-572-�552 PERMIT APPLICATION Received By: +�
763-571-1287 fax CITY OF FRIDLEY Date ���� �� 1� �
EFFECTI V E 01 /0 I/201 1
APPLICATION DATE: ��;- � '� CL'�% "" � 1 YOUR E-MAIL/FAX `�?/! % ' `� a2 d ° �� � � �"' —
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
JOB ADDRESS:
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME: C. 1 � C'� �y��
TO NANT ADDRESS ��;��� // �O�Si S`.S'; t> ; Sf C1TY i�" STATI31��Z1P C:-��``}'�
PHONE: �t���� - -� �/ ` T C�/� � .+�'�' -
CONTRACTOR NAME: r' � --1.- `t °'' -
SUBMIT A COPY OF .
YOUR STATE
ADDRESS: Cj�f �� �'�Z� �a �CfJ CITY (,(�(� �" �G�"'7 ('Y� STATE �'�ZfP !��_,�; i�j
LICENSE WITH PHONE `JL'7 °.5,�7 — .?� %L{ - ELL PHONE �t�> � — .:aZ�! — �.3 J"�
APPLICATION
STATE LIC # C`�7 7 �--��,� - /� )/` STATE BOND: � EXP DATE: � �- �/ ( /
1. Na� rative/written description: �
,� / !� �„-',"���, ,� :i �L�"�-�l'°iG ����"/%L)� i �' /%�c.c� � f ...� c� :
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations:
PERMIT TYPE
C! SEWER CONNECTION PERMIT ,� SEWER DISCONNECT PERMIT $50
I_l WATER CONNECTION PERMIT C' SEWER DISCONNECT PERMIT $50
^� WATER LINE REPAIR $40
`�SEWER LINE REPAIR $40 L�( � --�
C:� ADD STATE SURCHARGE $5.00 for each permit S"`
�� SAC CHARGE @ $2230 =
� TOTAL � � �J �—"
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 SHUT-OFF / EVENINGS, wEExENDS & HOLiDAYS $125/HOUR-BILLED
THIS IS AN APPLICATION 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 conformance with the ordinances and codes of the City of Fridley. I understand this is not a permit but
only an application for a permit and work is not to start without a permit.
SIGNATURE OF APPLICANT� �� PRINT NAM � DATE: �-�- ��
_.., �
APPROVED BY: � 4�� DATE: � `� f ��
COPY GIV�N TO �� UTILI Y BILLING (only if new meter) �l PUBLIC WORKS ENGINEERING
�` City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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ES WEST CONCORD, MINNESOTA • FARGO, NORTH DAKOTA
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56113 STATE HIGHWAY56 • P.O. BOX 68 • WEST CONCORD, MN • 55985-0068 • 507-527-2294 • FAX 507-527-2296