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�rig�neering WATER AND SEWER Permit No.:
763,572-3552 PERMIT APPLICATIQN Recei�ed By:
�/ �7 CITY OF FRIDLEY � �H'�� �
/ 63"5 / l-1287 fax EFFECTIVE 01/01/201 L e
APPLICA'FION DATE: I",� �'" l I YOUR E-MAIL/FAX: �? �� V�t.Ile.c.�� •(� r G I� ; Gd/►'�
THIS APPLIGANT IS: ❑ OWNER �5f CONT1tACTOR , `
JOB ADDRESS: ��-�iL— v i�;j],1�1 �9 °1q �� � W a'�1 I� .�- � r.
NEW CONSTRUCTION PERMIT# (IF APPLICABLE): '
PROPERTY NAME: P..r l� q 2 1 5 S, . -
:- owNER/ a,nn�ss: 2-�'bI L-o wr� ,,,�,,,,� �F ci�rv`,�1-�r�l�.u,•� srArs�+�1 ztp'�i!'$ ;
: TENANT rxoNE: b i� _'� 0-6 -$�-6 6
CONTRACTOR NAME: Ua\�Q�j - jL:c. �. � 6. 1�[''�,,-Q '
SIIBMIT A COPY DF ,y /
YOURSTATE ADDRESS: )�/� ►�- ']7?n"�1�'�R^+ I�1) v� �CITY C' v�R S�0. S'TAT�1P� ZIP ��
LICENSE WlTH PHONE �' S a- U`{g ^�✓ D v a' CELL PHGNE: �/ a-�3 9'- �/ � ,
APPLICATION
STATE LIC # STATE BOND: EXP DATE:
1. Narrative/written description•i / �
��0.:f a'� (iJef"-i-er' S-�.rv�LR... (9°t � �, .
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2. P4ease attach sketch showing curb line, utility line, building, etc. witFi distanees on back page. °
3. Stipulations: •
PERMIT '�YPE
,
❑ SEWER CONNECTION PERMIT � SEWER DISCONNECT PERMIT $50
Ll WATER CONNECTION PERMIT �_, SEWER DISC4NNECT PERMI`T $50
)$ WATER LINE REPAIR $40 �'D
- - ;` SEWER LINE REPAIR $40 :
� ADD STATE SURCHARGE $5.00 for each permit S
� SAC CHARGE @ $2230 =
. TOTAL $ � 'LfS �
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING _
i NEW WATER METER COST - SEE UTTLITY BILLING
SPEGIAL ASSESSMENTS - SEE FINANGE
WATER TAP - SEE ENGINEERING �
NOTE: WATER METER REPAIR, INSP OR SHUT-OFF / EVENINGS, WEEKENDS & HOLIDAYS $125/HOUR-BILLED
THIS IS AN AP�I.ICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED '
I hereby apply for a water "or sewer (new connection or repair) permif and I ackr�owledge that the information above is cotnple#e ai►d
accurate; that the work will be in conformance with the ordinances and codes of the Gity of Fridley. I understand this is not a permit but >'
_ only an application for a permit and k is no start without a penmit. .
�
SIGNATURE OF ABi,I�F T �L� PRINT NAME: �� p Q.. O� dY�i DATE: �/"" I ^ �
_ �---- {
APPROVED B : �, �'{ '' D�ATE: � I�
COP� I O: ❑ UTILITY BILLING (onty if new meter) � PUBLIC WORI�S .=i ENGINEER NG
City of Fridley
Engineering Department
6431 Univer'sity Avenue NE, Fridley, iVIN 55432
763-572-3552
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FAX. 763-571-1287
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Park Plaza Estates (� (1 J�� �� n. (1V� in ' es residence of manager
Manufactured Home Community ` � �-Lk
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Fridley, MN 55432 �
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Manager: Garrett Hendrix �
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