P - 35183Engineering WATER AND SEWER Permit No.:� L= "�
763-572-3552 PERMIT APPLICATION Received By:
76�i-�_71�-1287 fax CITY OF FRIDLEY Date Rec'd:
EFFECTIVE Ol/01/2011
APPL(CATION DATE: �� � J I� YOUR E-MAIL/FAX: �c.P CY; _ ( �; L _
THIS APPLICANT IS: ❑ OWNER j$�CONTRACTOR
.IOB ADDRESS: I� I� C►�U c^.���'fa J"i r�� IJ �-
NEW CONSTRUCT►ON PERMIT# QF APPUCABLE):
PROPERTY NAME:__.,p�,,Ic DIc2� ��-ih-�s •
OWNER/ pDDRESS: CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR Np�vtE: �,I' /1\`.c.ca � �Z: c (� C°v , , �'-,•� c .
SUBMlT A COPY OF �DRESS: I�{'i v1C 9.�i! n��nn ( v //
YOUR STATE � uI �7' CITY C� SfS�� STATEM�ZIP S (�
LICENSE W/TH PHONE ��r� `{/i-/ �� ?j D c� � CELI, PHONE: 6� a'��j`� ��S/ j)
APPLlCAT/ON r
STATE UC # O/� �r STATE BOND: EXP DATE:
1. i�larrative/written description:
Q...cp a`, � G� A-�r �� r�:�� ��- r -�r�`� `e l'
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations:
PERMIT TYPE
C' SEWER CONNECTION PERMIT I SEWER DISCONNECT PERMIT $50
I. WATER CONNECTION PERMIT I WATER DISCONNECT P�RMIT $50
I WATER LINE REPAIR $40 yp
I SEWER LINE REPAIR $40
I; ADD STATE SURCHARGE $5.00 for each permit �
I SAC CHARGE @ $2230 =
TOTAL $ � �
OTHER CHARGES (tF 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, WEEKENDS & 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 foc a permit and ' not to start without a permit.
SIGNATURE OF ANT PRINT NAME: f�'p Q_ _!, � S� hI DATE: � �� ��
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APPROVED BY: DATE: �
COPY GIVEN TO: r.� UTILITY BILLING (only if new meter) l_i PUBLIC WORKS l� ENGINEERING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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