P - 48496.-
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��ngineering WATER AND SEWER Permit No.� �`
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�' ' PERMIT APPLICATION Recei�ed By � �
763-572-3552 �
' CITY OF FRIDLEY � �
763-571-1287 fax EFFEC�vEOiio,r�o„ �,f��'�� �
i � APPLICATION DATE: F�----c7rt'D I' l q'� �,I YOUR E-MAIL/FAX: '�to� � 4�q � IG41 "� �,` L 1� •�U M'1 _ li
THIS APPLICANT IS: a, ��7 OWNER j1�CONTRACTOR �� -
30B ADDRESS: � a"� b � n�►"'1!O'` L1�1 � I�t� �a N IV �' � r
NEW CONSTRUCT[ON PERMIT# (IF APPLICABLE): �- � � -
1 PRO�ERTY , NAME: �+r 4.- � zo. � S > , .
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OWNERI ADDRESS; �S� I G.OW f ti /�� fJ � CITY S !�M-�JYUi STATE � iP S�S ��
TENANT PxoNE: 6/� -�0 6-�'f�} � 6 � i
CONTRACTOR NAME: A l - ;C o . , , _ \ _; -
SUBMITACOPYOF ADDRESS:��IZ N.�ilv�.°f�r+ nj)v� �`�' CITY C 'gS k`� STATE�"1r'�'LIP �!$
YOUR STATE
LICENSE WITH PHONE 9S�}"Y�,��'�8D %� CELL PHONE: �IoZ�� �''39 ^�S/ Z�
APP�ICATION ; � �
STATE LIC # STATE BOND: EXP DATE:
I
1. Nar-rative/written description: : # � �
d�e,0°a�� r � `' � ��r' � �V'!cc-s- �° �—' , �
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` "�> 2. Please attach sketch showing eurb line, ntility line, building,:etc. with distances on back page.
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3. Stipulations: . i
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< PERMIT TYPE I
❑ SEWER CONNECTION PERMIT � SEWER DISCONNECT PERMIT ' $50 �
� ❑ WATER CONNECTION PERMIT �_� SEWER DISCONNECT PEIt1V�IT $50 I
- � WATER LINE REPAIR $40 D �
� SEWER�;INE REPAIR $40
'� ADD STATE SURCHARGE $S.00 for each permit ' �
� SAC CHARGE @ $2230 =
, �
� TOTAL $ ' �� ;
OTHER CHARG�S (IF APPLICABLE) PAY TO UTILITY BILLING � '
NEW WATER METER COST - SEE UTILITY BILLING �( ,
SPECIAL ASSESSMENTS�- SEE FINANGE I
WATER TAP - SEE ENGINEERING , I
NOT'E: WATER METER REPAIR,INSP OR SHLTT-OFF / EVENINGS, wEExEt1D5 � Hot:tbAYS $125/HO R-BILLED I
THIS IS AN APPLICATION FOR A PERMIT-NQT VALID UNTIL PROGESSED I
I hereby apply far a water or sewer (new connection or repair) permit and 1 acknowledge that the information above is com ete and
accurate; that the work wild be in conformance with the ordinances and codes of the Gity of Frid(ey. I understand this is nof a i# but
only an application for a permit and work " t to start without a'permit.
SIGNANRE OF ANT �"""'�INT ME: �� d Q• �
O rS d►� DATE: I' I f~' � V
, APPROVED BY: a. ` �� � DATE: C' I
,;. - �,.-� � _
CQPY GIV,i�EN TO: ❑ UTILITY BILLING (only if new meter) C] PU$LIC WURKS :-� ENGI EERING ,�'�
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= City of Fridley
, ::,� �
Engineering Department �
6431 University Avenue NE, Fridley, MN 55432 ` �
763-572-3552 �
FA�: 763-571-12$7 �
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Park Plaza Estates
Manufactured Home Communily
Fridley, MN 55432
Manager: Garrett Hendrix � 612
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12Q2
12$6
1280
1274
1262
1253
1248
1242
1236
1230
1224
1218
1212
1206
1200
Frontage Road
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(1Vn indicates residence of manager
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Fence Along Property Line