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P - 74966a^.;;: �:,�`; . , '� .. _ . ;� . +.a.:_. .,.�w . ::�' k ! .: ;tai CITY OF FRIDLEY �'/ WATER AND SEWER CONNECTION PERMIT APPLICATION Ns�rie: �•� f f,;'"r�� J cJY�_�Cl;'�y Date• !�� f� 1g� (Nonr ow .r a Piumb�►) �� : /a!`7!.� � � �..t:.�r; ��- �`%��.�,� �^ �>r- _ ' LEGAI DESCRIPTION PERMIT: 8EWER: �y WATER: -`'� METER: FEE: �� FEE: �� L� DEP061T: O-DAPTER: — . .SiATE � � � $TATE r" e SURCHARGE: ^-? �' SURCHARGE: "�� TOTAL: �-•'r� '� �� TOTAL: f ` ~ 'S� TOTAL: � GRAND TOTAL: '`"� � � � S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTINO STRUCtURE•` � NEW STRUGTURE: BUILDINC, PERMIT No.: SEWERMIATER PERMIT NO.: 9� l0 8rECIAL ASSESSMENTS: Siqned�� '��'�� - `t.--�,,...---gY � f)- i3 .l.u". ��--.—.-r �,t� � S�.