P - 48471Engineering WATER AND SEWER Permit No.: U �1�
763-.5'2-3552 PERMIT APPLICATION Received By:
7�3-571-1287 fax CITY OF FRIDLEY Dat��'�c�l: �
EFFECTiVE 10/27/2010
APPLICATION DATE: ��Z- `� ' �O YOUR E-MAIL/FAX: —
THIS APPLICANT [S: ❑ OWNER �CONTRACTOR
JOBADDRESS: I�GC� SkYl,t2��1i1 I� IVF
NEW CONSTRUCTION PERMIT# (IF APPLICABLE).
PROPERTY NAME:�Zj l. Al�i i v��St
OWNER/ ADDRESS: CITY STATE_ZIP
TENANT pHONE �Ca�- S%1 � ���5
CONTRACTOR NAME: �i 11�1F 11�11�
SUBMITA COPYOF pDDRESS: ZZ�j C� CAPP �� . C►TY �A11�1T�R i STATE�Z[P���
YOUR STATE
LlCENSE W/TH PHONE .-Si- �'`� S'-C� (�Z�� CELL PHONE:
APPLICATION
STATE LIC # STATE BOND. EXP DATE,
1. Narrative/written description:
�,�r'sT�� ��.4� fL Ol�i �11-f � �`—�-1,v��j �(E � ` �z t.� � t A ) S LF� ViA 1 /—r f'i `.
Sr N 4(� 'TD i7d� ,�qA-I IJ
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations: d����cCf S�rCe+ Q�GI CKJ`6 . Fe��n�� C�Di1V12YI'��y�t5 (,�ji1-� S�%GiH�pSs
Stee( 6a�d s Pro��'r�e prd�Oev� �v�a�'��e a�.c1 sa�'e�`a- p,�U,s�,o,�s,
—T
PERMIT TYPE
C SEWER CONNECTiON PBRMIT .:, SEWER DISCONNECT PERM[T $50
�:l WATER CONNECTION PERMIT i' SEWER DISCONNECT PERMIT $50
: i WATER LINE REPAIR $40
� SEWER L[NE REPA[R $40 D
I! AD STATE SURCHARGE $5.00 for each permit
J SAC CHARGE @ $2100 =
TOTAL $ V J �
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING
NEW WATER METER COST— SEE UTIL[TY B[LLING
SPECIAL ASSESSMENTS — SEE FINANCE
WATER TAP — SEE ENGINEERING
NOTE: WATER METER REPAIR, INSP OR SHUT-OFF / EVENINGS, 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 conformance with the ordinances and codes of the City of Fridley. I understand this is not a permit but
only an application for a permit and work is not to start without a permit.
SIGNATURE OF APPL(CANT PRINT NAME: i�k IT�1�Z L,� DATE: I Z' �— )fJ
r j
APPROVED BY: � �C DATE: I L- g"' / Q
COPY GIV N TO: ❑ UTILITY BILLING (only if new meter) �1 PUBLIC WORKS - ENGINEERING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
I h S�t � t r 0�^ 763-572-3552
��� �e,�� � FAX: 763-571-1287
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