P - 48487Engineering WATER AND SEWER Permit No.: �G �� a�
763 572-3552 PERMIT APPLICATION Received By: �1'Gry� •
7G3-571-12g7 faX CITY OF FRIDLEY ��e�� `�01
, EFFECTIVE 7/1/2010
APPLICATION DATE: 1 G' r S' � C�% YOUR E-MAIL/FAX: _
THIS APPLICANT IS: ❑ OWNER ,C�CONTiZACTOR
JOB ADDRESS: f
NEW CONSTRUCTION PERMIT# (IF APPLIC LE):
PROPERTY N�: � �' � ���,, ; ,,�.
OWNERI ,,�DRESS: �251 C�t.�,;C ✓ S'� CITY �kr�r! STATE ZIP
TENANT
PHONE:
CONTRACTOR NAME: �r � <' tp�� �!�-�r `�' Scwef
SUBMITACOPYOF �DRESS: �?'GG /Gv�r� 14u�t �✓� CITY /�i•r.7,�-, /a,',s' STATEn,K/LIP SSW/�
YOUR STATE -!e
LICENSE WITH PHONE G �2 — �7 �� � G � 6 � CELL PHONE: 76 :T -� r+' %7 " �'� % `�
APPLICATION
STATE LIC # STATE BOND: EXP DATE:
l. Narrative/written description: 1
f1-�fX �d"' �anlc-:r���S�.urC,r- 4 t 1v1c, �'V`
2. Please attach sketch showing curb line, utility tine, building, etc. with distances on back page.
3. Stipulations: �o �C2.� 5'7YL.E �� S'T?�-/�L��S' 15�9�5-
Z• C i� mOi4CTi� � rn zS /421� 1) � E�5 lTY / F�T/�J6 C� 2 2) �J
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�. C�'Tj' 7'"`� J.�JS�E RMIC T�Y��CTcw.s Oiz ��,/L- 'Tv t3s`�CIL F�e. �, 763 —
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❑ SEWER CONNECTION PERMIT $50 '�s O S�
❑ WATER CONNECTION PERMIT $50
❑ WATER LINE REPAIR $40
❑ SEWER LiNE REPAIR $40 (.�
❑ ADD STATE SURCHARGE $5.0o S
❑ SAC CHARGE @ $2100 =
TOTAL $ u �v�
OTHER CHARGES (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, INSP OR SHLJT-OFF / EVENINGS, WEEKENDS & HOLIDAYS $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCE$SED
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. I understand this is not a permit but
only an application for a permit and work is not to start without a permit.
SIGNATURE OF APPLIC T PRIN NAME: � c F, a�SGt�. DATE: 0� S-/
APPROVED BY: DATE: G /
COPY G N T :❑ TILITY BILLING (only if new meter) ❑ PUBLIC WORKS ❑ ENGINEERING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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