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En�neering - WATER AND SEWER permit No.:
PERMIT APPLICA.TION '
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76r�-572-3552 Reeeivec� By:� `
����� � CITY �OF �FRIDLEY �
63-571-128% fax ' EFFECTTVEO�iori2ori �e�'� � � '�%i'i'�
APPi,IGATION DATE: f� Il YOUR E-MAIL/FAX: , f
THIS API�LICANT 13,: / " O ER �CONTRACTOR •
IOB ADDRESS: 'F Q 1. �� C.E_ �� �=vr ►4-�—
NEW CONSTRUCTION PERMIT#{IF APPLICABLEJ:
PROPERTY NAME: /Fn cc._ A-o�+►.+..s'
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OWNER/ ADDRESS: S� 9 : c� C 1c,.'"Q4�1R' �� STA'T� ��fA 3'r
, , TENANT pHONE: %to ? �: ?"' - Z c. P
CONTRACTOR xAtvtE: �t.�,...s Lv� �t a�.d Scw�4�-
SUBMITACOPYOF ADDRESS: �/3w �t,+�'•� �}-- ''�� S,} STATE�LI� �rp
YOUR STATE '�� : CITY ���
LIGENSE WITH FH6NE 10�2.• 78'!, 3? 3� C&LLPHONE: fD1Z-��i' 2Y�
APPLICATION '
STATE LIC # STATE SOND: EXP DATE:
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1. Narratiy�written description: ,
14�G;,, s�,.,.R, ��. �,,�,,<l � v.�d�►• i cl.�.»✓�. , ,�
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page. ,
3. Stipulations: �-CiN, � Wj�� �S%I� A�G{ c��� s�i�e� %2 W,��t��UfnS, �iSl�°
Pd'oped` CoMiDa� �ah I�i�oc�S on 6ack���. ��sccse ql( Con»eef�o�\s fo �y�'s��:�,�
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�ipe �s wu�es �.���-. Cail �63 -572�3SS6 irat� ��s�ec��dH pv�sa/� �p
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, PERMIT TYPE
❑ SEWER CONNECTION PERMIT � SEWER DISCONNECT PERMIT $50 �
❑ WATER CONNECTION PERMIT �_, SEWER DISCONNECT PERMIT $50
❑ WATER LINE REPAIR $40 � _
� . .�' SEWER LINE REPAIR �: $40 , � �
L ADD STATE SURCHARGE $5.00 for each permit : `
, ❑ SAC CHA'RGE ' ' @ $2230 = . ,
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TOTAL $ ,
OTHER CIiARGES (IF APPLICABLE) PAY TO UTILITY BILLING � `.
. . ` NEW WATER METER COST - SEE UTILITY BILLING' , ; .
SPECIAL ASSESSMENT� - SEE FINANCE '�
WATER TAF - SEE FNGINEERING
IVOTE: WATER METER REPAIR, INSP OR SHUT-OFF / EVENINGS, wEEKErrDS & HoLiDAVS $125/HO�JR-BILLEIY
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PRQCESSED � �
T hereby apply for a water or sewer (new connection or repairj permit and I ackno,wiedge that the information above'is complete and'' �
accurate; that the work will be in conformance �vith the ordinances and codes of the City of Fridley. I understattd this is notta ptrtnit bu#
only an application for a permi ork is`not to start without a permit, ''
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� SIGNATURE OF APPLICANT �� PRINT NAME: 'L �,Z �l�I�!'F-- ` DATE: �/
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APPROVED BY. BATE:
COPY GI T�: ❑' UTI ITY iLLING (only if new meter) [7 PUBLIC WORKS ._� ENGINEERI1�iG
City of Fridley � �
- Engineering Departnnen�
� 6431 University Avenue NE, Fridley, Iy1N 55432
, 763-572-3552
FAX: 763-571-1287
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