The URL can be used to link to this page

P - 48495� . � � � .. . . , . � . . . .. . . . . . . , . . , .. . .i. � . " � . ... . Engineering � WATER AND SEWER Permit i�o.: ` - 763-572-3552 PERMIT APPLICATION - Received B _ � �?�63-571-1287 fax CITY OF FRIDLEY , �� EPFECTIVE01/0112011 � � `APPLICATION pATE: �"�' /- I( YOUR E-MAIL/FAX: �¢ rJ� ��i°�I��.`�- f t �L. . C o rK �� a.�'�F r 3 3b� THIS APPGICANT IS'. ' ❑ OWNER .�CONTR.ACTOR - JO� ADDRESS: % cs�� I � I1 n►1 � �Lal � S� _ I� �. ; NEW CONSTRUCTION PERMIT# (IF APPLICABLE)'. � ' ' PROPERTY NAtvtE: k. I�2a, � S OWN�+R/ ADDRESS: 5�}n�G . CITY STA'FE ZIP . TENANT PHONE: � , » CONTRACTOR , NAME: �J R 1\,2. �+1— �. L(.� L° a_, i'►� e- SUBMITACOPYOF ADDRESS:`J�/'% �� .. �n� ' � ' \ 1L,q.�. 31� � t �/ c►�r e G� s�� sTnT�n�7 zi�� 5�'3�g , � YOUR STATE � llCENSE WlTH PHONE �7 �i � "�{�i/SS' - 7/ vfJ'-- CELL PHONEi ?SloL. � �3 � � $'�i � � APPLICATION - STATE T,IC # r STATE BOND: � EXP DATE: . , t , L . NarraNve/written description: ', % ��; r h (,v�,�J'. ,n,l�' ,� , ;' _ � 2. Please attach sketch showing curpline, utility line, building, etc. with distances on back page. 3. Stipulations: ' C�) I Kerey,, -�o,� �nspcel�;d� (��';ol` 1-� �uck �''1� � � � � � ��—� � � �� > ; _ I � � ; , , PERMIT TYI'E ; . , - ` ❑ SEWER CONNECTION PERIvIIT � SEWER DISGONNECT PERMIT > $50 � ❑ WA'T�R CONNECTION PERMIT �_; SEWER DISCONNECT PERMIT $50' ;!�c WA'�ER LINE REFAIR ` $40 . ` , � SEWER LINE REPAIR $40 _ L ADD STATE $URCHARGE $5.00 for each permit � D SAC CHARGE @ $2230 = , . . .. . . . . _ . . ' ., y .. TOTAL $ �/� , , CITHER CHARGES (IF A�PLICABLE) PAY TO UTILITY BILLING '' � � '. NEW WATER NfETER COST — SEE UTILITY BIL�,ING SPECIAL ASSESSMENTS - SEE FINANCE ' WATER TAP — SEE ENGINEERING , NOTE: WATER METER R�PAIR, INSP Oit SHUT-OFF / EVENINGS, wEExEN�s & HoLtDnxs $125/HOLIR-BILLED � r ' THIS IS AN APPLICATION �OR A PERMIT-NOT VALID UNTIL PROGESSED I hereby apply for a water or sewer (new connection or xepair) permit and I aeknowledge that the information above is complete and aecurate; that the work wilt be in,conformance with xhe ordinances and codes of the City of Fridley. I understand this is nof a percnit but only an application for a permC�or ' ot to start without a permit. . � � t� , SIGNATURE OF A ICANT � . PRINT NAME: � f� � r C� I S d 1.1 DATE: d' `�'' �� 1 - APPROVED BY: � , DATE: ,�. -'7 -1 ( , ��pY �iT Z'�: ❑ UTI TY ILLING (oniy if new meter) ❑ PUBLIC WORKS :_� ENGINEERING _ City of Fri-dley , " - ` Engineering Department - 643I University Avenue NE,: Fridley,'MN 55432 = �; 763-572-3552 FAX: 763-571-1287 � , �. f�, ; , , �,� a____� � �� u' � C�1�� -' ' �� Y� �y� � � � �� !� � .�, �. � � � � l�� 5--�' � ��,� �� c�. S. y � � �� .-^'�"� � � � � --�----- " )d ��p� � --�C ---� ___ a�` 1 � � i� .f ' .� � j� �}�l��G►� �- ��- �; ��,�a � �� w � �� c�� -----� °-�� i �3I a� � � 1�:3�� >► 0 -� � �1�� 5�--�--__ i=�.'' �:� �� :� �