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P - 74955CITY OF FRIDLEY WATER AND SEWER CONNECTION PERMIT APPLICATION Name: f��( �'C�. t�c�tv-S% Date: � J� 19� (H me Owneryu.plumber) Job Address: � �� 0 �'�� _ � T�, �f �2 C � � LEGAL DESCRIPTION PERMIT: � TRACT O AODITION � 7�� - C_L�� ti- .�--�- / SEWER: WATER: METER: FEE:��'''�v FEE: �°�/,J DEPO6IT: O-DAPTE R : STATE .�� STATE - cJ�U SURCHARGE: T_ SURCHARGE: TOTAL:�S S� TOTAL: /� S� TOTAL: -� ': �`''�' � / �U �� GRAND TOTAL: S.A.C. CHARGE ON EXISTING STRUCTURE: EXISTING STRUCTURE: NEW STRUCTURE: BUILDING PERMIT No.: SEWER ER PER IT�`� �` SPECIAL ASSESSMENT :� � ` � �� Sign By:G� � c�'z ,� �-