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P - 74960, CITY OF FRIDLEY WATER AND SEWER CONNECTION PERMIT APPLICATION Name ,� t%� � �v � x_� i� �'-0 i (Home Owner Plum r) _Inh Orlr�rccc• /�. l�� !��- �a / LEGAL DESCRIPTION / �c, 1�7� ti/ Date: �� 19 �-, � _ /1/ PERMIT: �J � v SEWER: G�� WATER: �'�' �� METER: FEE: FEE: DEP061T: O•DAPTER: STATE �� Q STATE � Q SURCHARGE: SURCHARGE: � � TOTAL: 5" �`� D TOTAL:/� �� D TOT ;�/ O O ��/ o o . GRAND TOTAL: S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: NEW STRUCTURE: BUILDING PERMIT No.: � SEWER ATER PERMIT NO.• �`'� SPECIAL ASSESSMENTS: �%� f�� Signed: � �� ' �,�In1�;I�(c� " By: