P - 44456Engineering WATER AND SEWER Permit No.: (
763-572-3552 PERMIT APPLICATION Received B:�
CITY OF FRIDLEY , �j1;��
763-571-1287 fax EFFECTIVEOI/Ol/2011 Date �
APPLICATION DATE: � � r I`j' �� YOUR E-MAIL/FAX: _
THIS APPLICANT IS: O OWNER '� CONTRACTOR
JOB ADDRESS: � l.� • {� E. ��f' i G 1��{ �i �(1 ��J� 432
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME: � '�i' IS
OWNER/ ADDRESS: �p� (p�{ 0�' �.�ii • N� CITY iC�� STATE��IP SSy32
TENANT pHONE: EDIZ'�$ —��id°J
CONTRACTOR NAME: � US r(
SUBMITACOPYOF ADDRESS;_ �LZ7 A CITY U STATE/�� ZIP SII
YOUR STATE � �r� u1.1� �
LICENSE WITH PHONE CELLPHONE:
APPLICATION
STATE LIC # CJ STATE BOND: EXP DATE:
1. Narrative/written description:
S�ra.r �0.�; r t� �� ; n 3a�l�.�c� �j� q�-I— (�st2/�' �� loX y,' Ccn r1 ec�►`o n
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations: u S�. ��` �j 1 vl �f S S 1..� ��� 4t �. C� Q v►1' T� t * P S✓� ('0 �S N%� �2 �1
c{��o(�eu�lt� ContJ��e'�a�^ �� �feS��hs�ble �c+r daw�u�e �o Cuv�b aNCI St✓P
Cul) Z� hou�rs 6e�a�`e `nsPce�;��S,
PERMIT TYPE
❑ SEWER CONNECTION PERMIT ❑ SEWER DISCONNECT PERMIT $50
� WATER CONNECTION PERMIT ❑ WATER DISCONNECT PERMIT $50
❑ WATER LINE REPAIR $40
�C( SEWER LINE REPAIR $40
❑ ADD STATE SURCHARGE $5.00 for each permit S�
❑ SAC CHARGE @ $2230 =
TOTAL $ ���J
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING
NEW WATER METER COST — SEE UTILITY BILLING
- SPECIAL ASSESSMENTS — SEE FTNANCE
WATER TAP — SEE ENGINEERING
NOTE: WATER METER REPAIR, INSP OR SHUT-OFF / EVE1�iING5, 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 �no o start without a permit.
SIGNANRE OF AP AN PRINT NAME: lUr� D{1 `'�dr O.(Yl 6GATE: I� � /'�
a
i ��-
APPROVED BY: ; DATE:
COPY GIVEN TO: ❑ UTiLrTV Bi L NG (only if new meter) ❑ PUBLIC WORKS C ENGINEERING
City of Fridley
Engineering Department
6431 University AvenueNE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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