P - 40011�ng:�r�eering WATER AND SEWER Permit No.: �-Q
763-572-3552 PERMIT APPLICATION Received By:_���
763-571-1287 fax CITY OF FRIDLEY
EFfECTIVE 01lO1/201I D`����������
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APPLICATION DATE: f ^G / _ YOUR E-MAIUFAX: ��.,Ce..,�_ �./ ,.1 a l yl�l',�.� �/ Ge-'[� � G c�
THIS APPLICANT IS: �IER CONTRACTOR
.IOB ADDRESS: � /- �
NEW CONSTRUCTION PERM]T# (IF APPI,iCABLE):
PROPERTY NAME: N`� �Cl�QE�L
� �A � ADDRESS: � .� �� GS . s2�— C1TY ��! STATE�I!LIP ..if
PHONE:
CONTRACTOR NAME: � cc� l�i- a
SUBMIT A COPY OF �DRESS: ,S�S�.{� �-']CJ � � C[TY �lG�'E� STATE l'7•°�LIP�(�Ci
YOUR STATE �/
LICENSE WITH PHONE �1,5��' 7 l� ��.�.� CELL PHONE: �I��1 7�J" �7f G
APPLICAT/ON /
STATE LIC #! �� STATE BOND: G' (� � EXP DATE: �
l. Narra ive/wr�tten d/�gscription: / /
� � �ra. !/' A �c.� �.�" � �e r� !"`O 1'a I' �C'J�� � µ P � o � .i��rc �
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations: , w � � �j i�(�'TG�i , G. ��Dy�ry�� �
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�b3 57Z 3552
PERMIT TYPE � to 3 572 355�0
��3-23s1-�aHB
I' SEWER CONNECTION PERMIT I SEWER DISCONNECT PERMIT $50 76� — 23g'�3058
I. WATER CONNECTION PERMIT I WATER DISCONNECT PE��Q���
I WATER LINE REPAIR v•��
I SEWER L[NE REPAIR $40 �fU �'
I ADD STATE SURCHARGE $S.00 for each permit S'�
I SAC CHARGE @ $2230 =
TOTAL $ �S �
OTHER CHARCES (IF APPLICABLE) PAY TO UTILITY BILLING
NEW WATER METER COST — SEE UTILITY BILLING
SPECIAL ASSESSMENTS — SEE FINANCE
WATER TAP — SEE ENGINEERING
NOTE: WATER METER REPAIR, [NSP OR SHUT-OFF / EVEN(NGS, WEEKENDS & HOLIDAYS $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VAUD UNTIL PROC£SSED
I hereby apply for a water or sewer (new connection or repair) permit and I acknowledge that the information above is complete and
accurate; that the work will be in conformance with the ordinances and codes of the City of Fridley. 1 understand this is not a permit but
only an application for a permit and c is not to start without a permit.
SIGNATURE OF APPLICANT PRINT NAME: �� 1�d ^� ,J�'-co y,��DATE: �4'Y l
APPROVED BY: DATE: � Z� L I
COPY GIV i:[: U ILITY BiLLING (only if new meter) l.� PUBLIC WORKS l� ENGINEERING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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