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P - 48498� , � , ; . WATER AND SEWER Permit�To.: � . ��ngineering � , 763-572-3552 PERMIT AP�LICATION Received By: � CITY O� FRIDLE 763-571-1287 fax EFFEC�v�ouoii2oii ��N � ' APPLICATION DATE: + ":) a - � ( YOUR E-MAILfFAX: �C� �- \i �I`Q K - f : G-1.. • �-�M THIS APPLICANT IS: ❑ OWNER [7�GONTRACTOR JOB ADDRESS: i a�I Di� c>�qG �� . N� NBW CONSTRUCTION PERMIT# (IF APPLICABLE): , PROPERTY NAM�: c� k � 41 S�i. �e �' , ONANT ADDRESS:�� I LU w� � AttiL 1`l �— CITY Si-� �..""�I�vv�� STATE�I� ZtPS��/ �' r PHONE: �ilex - �i0 i ' �i-L�-�j ��,� CONTREICTOR NAME: �AA lt.ey, - 'f� : �.L� Cr •� � �L— � SUBMITACOPYOF ADDRESS:I'��7 N • ��1�n°t�,� ��vo� '� `�CITY C ��15 "� S'TATE4�►�:.1Z1P� ` YOUR STATE - � • ; LICENSE WITH PHONE �J S � ' �i%� � - 3 0 d eZ. . CELL PHONE: � Io� - �3 �' � Sf � ` APPLICATl01'V : ' STATE LIC # STATE BOND: EXPbATE: - � L Narrativelwr'tten description: � � Q� f .'°� (�J xs /� n/ �� c�sz i2'n �-- . i � 2. Ptease attach sketch showing cu,rb line, utility line, bui(ding, etc. with distances 0n back page. 3. Stipulatio�s: : . �� _ PERMIT TYPE ` � � ; � ,❑ SEWER CbNNECTION PERMIT C SEWER DISCONNECT PERMIT : $50 ❑ WATER CONNECTION PERMIT Ci SEWER DISCONNECT PERMIT $50 � J8� WATER LINE REPAIR $40 D �� SEWER LINE REPAIR $40� , '�- ADI) STATE SURCHARGE, S5.00 for each permit � SAC CHARGE . - @ $2230 = . TOTAL $ �� r OTHER CHARG�S (IF APPLI�ABLE) PAY TO.UTILITYBILLING ` NEW WATER METER GOST - SEE UTILITY BILLING ' � SPECIAL ASSESSMENTS - SEE FINANCE > � � . WATER TAP — SEE ENGINEEWNG ' �� 1!�OTE: WATER METER REPAIR, INSP OR SH[JT-OFF t EVENINGS, WEEKENDS & HOLIDAYS $1z5JH�UR-BILLED THIS IS AN APPLICATION FdR A PERMIT-NOT VALID UNTIL PROGESSED � ' ' " I hereby apply for a water or sewer (new cannection or,fepair) permit and I acknowledge that,'t�e infprmation above is complete artd accurate; that the work will be in conformance with the ordinances and �odes of the City of Fridley. I understand this is qot_a permit but' ' � only an application for a permit and wor ' t to start without a permit. SIGNATUREO PLJ,CANT --RRINTNAMEr ��(' �.. 61 SO I--� DATE: I"��' �� , 9 APPROVED BY � ' DATE:, �� . . i COPY I E TO: ❑ UTILITY BILLING{only if new meter) C] PUBLIC WORKS �� ENG NEERING re.._. ,.rr,_:a�.._, � . . . . . ". . .�.+EI�J` Vl 1`11l.ilG,' . . .. . . _.. . . . . . . . . . . . . . . . ..�'` Engineering Department ' 6431 Universitj� Aven�ie NE, Fridley, M1�1 �5432 -- 763-572-3552 _ - FA}�: 763-571-1287 : , ; � � , , � � . . �� s• �� 1! `- �\. ��'�� . Park Plaza Estates (1Vn indicates residence of manager Manufactured Home Community S� �,' C. Fridley, MN 55432 Manager: Garrett Hendrix � 612-328-5432 1299 1293 1289 1283 1259 1257 1253 1249 1243 1239 1233 1225 1219 1213 1209 1203 1129 1123 1115 1109 7435 Highway 65 NE � �c�..s� L�� 1298 1292 1286 1280 1274 1262 1253 1248 1242 1236 1230 1224 1218 1212 1206 1200 1146 1142 1136 1128 1122 1114 1108 1100 128.i 128 12�7 12 1 12 7 12 7 12�7 12�1 3 12317 123; 122 122 121 1211 120 1201 �.Clrvvt Frontage Road 1143 1141 1139 1137 1131 1125 1119 1113 1107 1103 1 a �i c.�. n�c,1�..c�.� 1148 1142 1136 1130 1124 1118 1112 1106 1102