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P - 74957� CITY OF FRIDLEY WATER AND SEWER CONNECTION PERMIT APPLICATION Name: '� � � /�- �S � Date: g ' �� 1 y --� (Home Owne or Plumber) �o�� _ /J Job Address: _--- '�- I � iZ U ! � C...�/ /� �. �, PERMIT: .�--- SEYVE R : FEE: o7S OC� �---� WATE R : FEE: /�' v� METER: DEPOSIT: 0•DAPTE R : STATE , s� STATE � S � SURCHAHGE:�- SURCHARGE: �l TOTAL:�`� � TOTAL: /� '�U TOTAL: ��'°`,�� ;� � // 06 GRAND TOTAL: � S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: NEW STRUCTURE: BUILDING PERMIT No.: ---� SEWERMI PERM�r� SPECIAL ASSESSMENTS: Sign . � - � B : -c_