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P - 44454From: City of Fridley To: 7637867801 Page: 2/2 Date: 2/19/2010 12:27:13 PM Engineering WATER AND SEWER Permit No.: 763-572-3552 PERMiT APPLICATION Received By: CITY OF FRIDLEY 763-571-1287 fax ��,.��,;,,2010 �� c� APPLICATION llAT�:: I Q�%V YOUIZ E-MAILiN'AX: �� m.e�dernr��;�(—CL2�'?''� — TH1S APPLICANT 1S: ❑ OWNEK ❑ C'ONTRACTOIZ `� �o�A�u�zr.ss: IZ�oO ON�71�1pgf,A DR f�1z.. �FLtv�!`T� 572��T NtW CONSTRUCTION PERMITt�(IH APPLICABLE): PROPERTY NAME: LS � ING G` T NANT A°°��.ss: U so Fi,-e�� ri v� C1TY �DI �I STAT��GIP 5�'7 PHONE: �!I � 3� 7 S 3� CONTRACTOR NAME: � l�1C. SUBMITACOPYOF A�llu�.ss: S3%DNJeST S S�y�/j[J �!•P CITY YOUR STATE ig�a►I'LP STATty%WGil�S� L/CENSEWITH PHONE ��oS78L?d�0 CtLL PHON�: 71p3 Z'�S aGZ7 APPLICATlON STAT� LIC it � V�� STATt BONU: (�f% EJ(P UATE: � 1. Narrativelwritten description:,p / f- � 1�¢ I�r. :✓ �� V/'D K$►"1 LrJ�GY 1� ��ji2�,�1 - � 2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page. 3. Stipulations: �, (/L�FlC �iuTr�t �Q � /� /� ST��T -�� Z. /�EEP �e.� S o � T oF SE�E � SY��i . TC� ��rt�0'�- 3. K�EP �Xc.ot�rt--r� inR��-�rrt�s 2� E � 5/�,� $7�/Lt��O pf STo�jL, .P�Lf.d �w—S�TE. PERMITT��F�SiTE SY ?�JNL !� 2oio� SEWER CONNECTION PERMLT $50 WATBR CON �TION PERMIT $50 WA1'ER LINE REPALR $40 �. � SEW LINE REPAIR $40 ADD STATE SURCHARGE $.50 , .SD SAC CHARCiE {c� $21UU = � _ TOTAL $ � •� OTHER CHARGES (IF APPLICABLE) PAY '�O UTILITY BILLING NBW WATER MBTER C05T — SEE UTlL1TY BLLGINU SPECIAL ASSESSMENTS — SEE FINANCE WATER TAP — SEE ENCiINEBRIN(i NOTE: WATER METER REPAIR, [NSP OR SHUT-OFF/ EVENINCiS, Wt�.KtNDS & HOLIllAYS $125/HOUR-BiLLED THIS 1S AN APPLICATION NOKA PERMIT-NOT VALIU UNTIL PROCESSEU I hcrcby apply for a watcr or scwcr (ncw conncction or rc:pair) permit and I acknowlc;dgc that thc information abovc is complcfic and accuratc; that thc work will bc in conformancc with thc ordinanccs and codcs of thc City of Fridlcy. l undcrstand this i.� not a permit but only an application for a permit and work is not to start without a permit. � � � ��/iD SIGNATURE OF APPLICANT �- PRWT NAME: rV C.►�, ��.(J1i✓) DATE: APPROVED BY: DATE.: z I P'c7 COPY GIV O. 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 r. k _ w ��1 v"� � X� cs1 �� 2 f� . . �% V _ ...� � � �- _ _ � � v � ' Q � � � � � � �a � �..r � �j � 3 � � � � 2 � � �, ,;` S� � � 0 �2� ZOii 90ii Ziii 8ili �Zii 0£II 9£ii Z�ii 8bii bOZi 80Zi OiZi Olli 0£ZI ObZt 99ZI OLZI 9LZI Z8Zi 88Zi £Oii LOii £III 6iII SZii i£ii L£ii �� 6£ii ibtt £bti a�n7 �fj�adold 8uo�d aoua,� O ,� O � b a � .f�: Z -� •w � � pnog a�n;uor,� 7aalts � IOZi LOZi iili LiZt illi LZZI i£ZI L£Zi ItiZi LbZi LSZi L9Zi iLZi LLZi i8Zi L8ZI OOii 80ii biii lliI 8ZIi 9£Ii Zbii 9�ii. OOZi 90Zi Zili 8ili blli 0£Zi 9£Zi ZtiZi 8bZi £SZi Z9Zi bLZi 08Zi 98Zi Z6Zi 86Zi . _ , ., �I S9 ��^�u�?H S£i�L 60ii Siii . £Zii 6Zii � £OZi � 60Zi � £IZi � 6iZi b Slli a �£zt � 6£ZI � £bZi 6bZi � £SZi a LSZi ''� 6SZi £8Zi � 68Zi � £6Zi 66Zi L08£-98L-£9L � ssn3aa ed iva�� :aa gaxy� �IU Z£fiSS 1�IL1I `�alP!a3 nmmo� acaog paan;�s;nauy� sa;�;s� ez�id �I��d