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P - 74956� CITY OF FRIDLEY WATER AND SEWER CONNECTION PERMIT APPLICATION Name: ��-'�-- �� Date: � �� 19� (Home Owner Plumber) Job Address: Cv"7 �°2 ��'1Z,(� ��„ �---� iZ�-(. � PERMIT: r/ ✓'' SEWER: WATER:�„_ METER: FEE: �� FEE: /°' �� DEPOSIT: O-DAPTE R : STATE , S� STATE , 5 (� SURCHARGE: T SURCHARGE: � TOTAL: ' S v TOTAL: /� TOTAL: -� �'' `'�' ! �_.� J�- ? �1 /J o v GRAND TOTAL: 7 S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: NEW STRUCTURE: BUILDING PERMIT No.: - -�; SEWER/,VCi , R PERMI O.c� ,' SPECIAL ASSESSMENTS� r�_` � Sign By:-,� �"