P - 48263Engineering WATER AND SEWER Permit No.: �
763-572-3552 PERMIT APPLICATION Received By:
763-571-1287 fax CITY OF FRIDLEY Date Rec'd: ��
EFFECTIVE 01/Ol/2011
APPLICATION DATE: � YOUR E-MAIL/FAX:
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
JOB ADDRESS: % � �Z %� + C.. �� .a I�' 6. /G� /G� � •
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME:_ /c �r�¢ ,' s c h,„; 1` Z
OWNER/ pDDRESS: l�.'; 2, G/��o rd rL..Q CITY STATE ZIP
TENANT
PHONE: �/ Z ,.,2 y'7 a Z. y O
CONTRACTOR NAME: '° �' � � G (�,9G�"
SUBMITA COPYOF ADDRESS: 7 TD -��� � ,�/ ,, ��� � Q
YOURSTATE � � � '"� C�T/Y�.D' ""''"'�-'� STATE ZIP -�3�U
LICENSE WlTH PHONEt'I� �j t.17 �'%i I'Z.. CELL PHONE: _ lp i 2- 2 S c7 "lc 3 Ci �'
APPLICATION
STATE LIC # STATE BOND: EXP DATE:
1. Narrative/written descripty'on: ^ y�, S c� �C�
� �% �/� [' �.2 / d � �i v� v /% Q-v+ � cz..e�..,� S -e r v � o � �'
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations: �l Se -�u' n t0 e� e� �� t► .� C Q�1 H t e f%d�s �,� j � r� S�u. k�e 5 S
SiC2� bQv�.�SF ��e�. OSII�- Srl%�� Stu�n�S QN(� �t"�Q�It� ��.��JQoi.
6cjt�(�i� YhQ1���Q.) , �—`�—
PERMIT TYPE
❑ SEWER CONNECTION PERMIT ❑ SEWER DISCONNECT PERMIT $50
❑ WATER CONNECTION PERMIT ❑ WATER DISCONNECT PERMIT $50
❑ WATER LINE REPAIR $40
0 SEWER L1NE REPAIR $40
❑ ADD STATE SURCHARGE $5.00 for each permit
❑ SAC CHARGE @ $2230 =
TOTAL $
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 REPAIIt, INSP OR SHUT-OFF / EVEI�iINGS, WEEKENDS & HOLIDAYS $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VALiD UNTIL 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 co rmance with the ordinances and codes of the City of Fridley. I understand this is not a permit but
only an application for a permit ork is not o st ithout a permit.
SIGNATURE OF APPLICAN7' f PRINT NAM . � (U/y� � DATE: �-�- � //
APPROVED BY: DATE: I Z �� I I
COPY GIVE �: ❑ UTIL BILL[NG (only if new meter) ❑ PUBLIC WORKS ❑ ENGINEERING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287