P - 48474Engineering WATER AND SEWER Permit No.:
763-�72-3552 PERMIT APPLICATION Received By:
7f_ p�7 CITY OF FRIDLEY ��'��"
�� 571-I20 / f� EFFECTIVE7/1/2010 D������ r��
APPLICATION DATE: � � Z- �l /� YOUR E-MAIL/FAX:
THIS APPLICANT IS: � OWNER �CONTRACTOR
JOB ADDRESS: J�'�i�-Sy �iC -e C�^.t � � �`G� �
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY N,�: �
OWNER/ �DRESS: �j y S � � C2 C Cp 2 K Q(t,�C, CITY �,� ,��-Q�STATE ZIP
TENANT
PHONE: �� 3 � Z 'Z �j' _. � � � '"L_
CONTRACTOR NAME: q ��
SUBMITA COPYOF �DRESS: 'S� C��wws,_. C- STAT ZIP �S3 ��
YOUR ST.9TE ��I v\ �� CITY �^��,�nn e
LICENSE WITH PHONE �(.�'2 ��`� l Z CELL PHONE: � 1 Z. 2 S o,- �� 9 S'
APPLICATION
STATE LIC # STATE BOND: EXP DATE:
1. Narrative/w en description•}
� � D � � �-- \ _�2.b. �C. �*. �.s� c�� p �r v r 'C �.. � S "� �r .� e� S � � -2.�
C) � C �r (3 l� oK
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations:
PERMIT TYPE
. ❑ SEWER CONNECTION PERMIT $50
❑ WATER CONNECTION PERMIT $50
J�C WATER LiNE REPAIR $40 °° .f C�
❑ SEWER LINE REPAIR $40
❑ ADD STATE SURCHARGE $5.00 .
❑ SAC CHARGE @ $2100 =
TOTAL $ f
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 SHUT-OFF / EVENINGS, WEEKENDS & HOLIDAYS $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LJNTIL 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 onformance with the ordinances and codes of the City of Fridley. I understand this is not a permit but
only an application for a pe i d work ' t to s without a permit
SIGNATURE OF APPLICAN PRINT N i � i�J DATE: Z ��
r
APPROVED BY: � DATE: I � �
COPY GIV Z'�: ❑ UTILITY BILLING (onty if new meter) � PUBLIC WORKS ❑ ENGINEERING
C;ity of r'ridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
r
�
s�
�
u
d
V
4
v
�
�.
�
�
�
�
�`
4
�
�
J
�
�
�
�
a=
t
�
�
�
�;
311