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P - 75047Name: CITY OF FRIDLEY WATER AND SEWER CONNECTtON PERMIT APPLICATION LLIr-�,vC'�. �-f�i 11 �. (/A L �w �� I'� ��.�� f Date: �� `� 1 (Homs Owrnr o► Plumb�r) r Job Addreas: �� D•� i�`i2 l/ i�- .[��.�%�j �� LOT NO. BL K � TRA O- rAD�D�'�ION LEGAI DESCRIPTION // �� `' C�L !Jf},+V f-fY LCS �/ ::� 1 PERMIT: SEYMER: `� FEE: �� U ✓ WATER: FEE: � � � METER: DEPOSI T: O•DAPTER: 3URCH GE: �� SURCHARGE: �� ..., ` � �.. � <. CJ TOTAL: ��- • � J TOTAI: /" ' `� TOTAL: ��j c/ U GRAND TOTAL: S.A.C. CHARGE ON EXISTING STRUCTURE: �/ EXISTING STRUCTURE: NEW STRUCTURE: BUILDING PERMIT No.: ��`�� SEWER/WATER PERM •� SPECIAL ASSESSUAENTS: � �� Siyned• � ey: �