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P - 74949f CITY OF FRIDLEY �--�- r WATER AND SE)IVER CONNECTION PERMIT J � L � � PPL�CATION � � Sc�� ,7i -J U� Name:i�G�-m ��y �R�v��e C-�-�4,L Date: �.�L f 19 cI� Home Owner or Plumber) � ��e � l�o� Job Address: � C� 3 �` C�p� LEGAL DESCRIPTION PERMIT: .� CT OR /�DDITION � iJ, �� . � --�` " �� SEWER: �_ WATER: METER: FEE: °'��"� CC� FEE: /✓ U�� DEPO6IT: �'�- UC� O-�APTER: STATE , J Gl STATE <� SURCHARGE: SURCHARGE: TOTAI: �`J `' `� TOTAL: /"' � �� TOTAL: `�(�' G�J � GRAND TOTAL: /C� / a � S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: NEW STRUCTURE: L BUILOING PERMIT No.: `��='?�� a SEWER/WA� PERM1 NO.: � ` SPECIAL ASSESSMENTS: (�,i �� Sign % `L`'�- P � =�-----" BY: �( ��, m V i ii� �f'J i l C' �° n'1':�_