P - 74954CITY OF FRIDLEY
WATER AND SEWER CONNECTION PERMIT
APPLICATION
Name: W � 0`
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Job Address: �'.
LEGAL DESCRIPTION
PERMIT:
C.�
Owner Plumber)
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SEWER: �
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FEE: �
B � cK
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'_ Date: �� �� 19�
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WATER: METER:
/ � Op
FEE: '� DEPOSIT:
l <.>�
O•DAPTER:
STATE � 5� STATE , S �
SURCHARGE:� � SURCHARGE:� �,��
TOTAL: TOTAL: TOTAL: _�f ' � �'
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GRAND TOTAL: �j U �
S.A.C. CHARGE ON EXISTING STRUCTURE:
EXISTING STRUCTURE: NEW STRUCTURE:
BUILDING PERMIT No.: SEWER ER PERNU 0.���
SPECIAL ASSESSMENTS:�'� ��% `�p '�� Sign f
BY, c