P - 80960Engineering WATER AND SEWER Perrnit No.:
'763-57�-3552 PERMIT APPLICATION ���.,� ReceivedBy:�fY��
� CITY OF FRIDLEY
763-571-1287 fax � �, � •
EFFEGTIVE 01/122012
AFPLICATION DATE: �� 0/ Z"'" YOUR E-MAIL/FAX:
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
aoa ,4nDxESS: S 3 � t c c� C cre :�- �� �-� i/� �
N�W CONSTRUCTION PERMIT# (IF APPLICABLE): �
PROPERTY N�: 'a C z.4 f.e ..v S�, "
O�ER/ ADDRESS: 'S' � 2� c e C�r �P ,a t! � CITY STATE 2{P
TENANT
PHONE: %G� 3 ^ 's c� 2. - / 3 '�` ��
�ONTRACTOR N,a�: � �-�'a :
SUBMIT A COPY OF »
YOUR STATE �DRESS: c'T'7 ,("� ,� �. -=,,... �Q/'� CITY L 3TATE Z1P,s�'O
LICENSE WITH PHONE�� -�i 7 rr -(o ? l 2. CELL PHONE: �n / 2- 2 4 b` 6�. g,;�"`
AFPLICATION
STATE LIC # STATE BOND: EXi' DATE: "
1. Will work take place in City ROW7 Ye No f yes, RC)W registration is required — see Engine�rin�.
2. Provide written description of proposed wor : i2c�,� t�,c� c�..a�'E's=, �s�Uv t c-�. .-..- C�.. � u�p ,'
� � Q� ��
3. Atta.ch plan/sketch showing proposed work with existing "curb, utilities, trees, buildings, etc. v�if� c�im�ians
4. Circle type of erosion control measures to be installed to prevent d.isturbed soils from erading:
Silt Fence Bio-rolls Erosion Blanket Sodding Other:
5. Provide minimum of 2 hr notice for inspection ( 8 am - 4:30 pm) and call in the following or�esr: ('��3� �"12-
3552, (763) 572-3556, (763) 238-8058, (763) 572•3562 or (763) 572-3551, or (763) 427-1212.
6. Refer to "Construction Requirements for Water and Sewer Work" on back of page. �
'7. Stipulations:
PERMIT TYPE
D SEWER CONNECTION PERMIT ❑ SEWER DISCONNECT PERMIT S50
�WATER CONNECTION PERMIT ❑ WATER DISCONNECT PERMIT $50
D. SEWER LINE REPAIR 1�WATER LiNE REPAIR $40
� ADD STATE SURCHARGE $5.00 for each permit ' -
❑ SAC CHARGE @ $2365 =
TOTAL $
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING
NEW WATER METER COST — SEE UTILITY BILLING
SPECIAL ASSESSMENTS — SEE FINANCE
WATER TAP — SEE ENGINEERING
N�TE: WATER METER REPAIR, INSP OR SHUT-OFF / VENINGS, WEEKENDS �c HQLIDAYS $125/iIOU�-�ILL�
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a water or sewer permit and I aclrnowledge that the information above is cvmplete and accur�te; Ehat #he vvork vyitl !ye in -
� confarmance with the ordinances and codcs of the City of Fridley. I understand this is not a permit but only an application for a pp�m�,t a�d
,� work is not to start without city rov f this permit application, unless emergency repair is requ�red. ;
SI(�NATURE OF APPLIQ�S1 ���� PR1N'i' NAME: �r� `Z l`� C� O'1/ �► DATE: �'/ :S < �:----- :
A�'ROVED BY: ��✓ DATE: �'�" ✓ d'- I Z' ,.
�O►PY G N TO: o u IL Y BILLING (only if new meter) � PUBLIC WORKS Q ENGIN$EI+tII�iG
C�ty of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
'763-572-3552
FA�: 763-571-1287
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