P - 47297Engineering
763-572-3552
763-571-1287 fax
APPLICA7'ION DATE: �'' Z Z ^ /
THIS APPLICANT IS: ❑ OWNER
WATER AND SEWER
PERMIT APPLICATION
CITY OF FRIDLEY
EFFECTIVE Ol/01/2011
YOUR E-MAIL/F.
CONTRACTOR
JOBADDRESS: ___ ��O pq�anra
NEW CONSTRUCTION PERMIT# (IF qppLICABLE):
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
Permit No.:
Received By: � � � i
Date �� i�Q�'
NAME:_c��-�c�it: -�( i;,1� � —�-�
ADDRESS. � � ~ r✓
CITY STATE ZIP
PHONE:
ADDRESS:_ �p�{�1 IS3 �`� L � � � CITY �r,��
PHONE _%(o�-- �S O--Co� � CELL PHONE: STATE h�i✓ZIP S� O�
STATE LIC # fn <I r 7 a_
DA
L Narrative/written
n ,. .
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations:
PERMIT TYPE
❑ SEWER CONNECTION PERMIT ❑ SEWER DISCONNECT PERMIT $50
O WATER CONNECTION PERMIT ❑ WATER DISCONNECT PERMIT $50
❑ WATER LINE REPAIR $40
❑ SEWER LINE REPAIR $40
I_, ADD STATE SURCHARGE $5.00 for each per`mit , S
Cl SAC CHARGE @ $2230 = '
TOTAL $ `�
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING
�W WATER METER COST — SEE UTILITY BILLING
SPECIAL ASSESSMENTS — SEE FINANCE
WATER TAP — SEE ENGINEERING
ATER METER REPAIR, INSP OR SHiJT-OFF / EVENINGS, WEEKENDS & HOLmAVS �
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT1L PROCESSED
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 Fridiey.l understand this is not a permit but
only an applicarion for a permit a�d work is not to start without a permit.
SIGNATURE OF
APPROVED BY:
COPY GI'�"EN TO: ❑
PRINT NAME: ��� DATE: �(� G Z^ I(
�
DA7'E: I�" 2 Z' I�
�n Y KILLING (only if new meter) ❑ PUBLIC WORKS C ENGINEERING
City of Fridley
Engineering Department
6431 UniversityAvenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287