P - 48468Eri '�leerill WATER AND SEWER Permit No.: �,�,.' �
%� ��-572-35�52 � PERMIT APPLICATION Received By'` �
763-571-1287 fax CITY OF FRIDLEY ��� ���>� Q i �Q
EFFECTIVE 10/27/2010
APPLICATION DATE: I� - I-� O YOUR E-MAIL/FAX: l0 ,7 �' � L�� - O�4 %� _ --
THIS APPLICANT IS, ❑ OWNER �CONTRACTOR
IOB ADDRESS ��L/� Is�M,lJa T�CrYG<,t _/�L.�— _-- ---
NEW CONSTRUC"TION PFRMIT# (IF APPLfCABLE) _ _ _ __ _.._ -- — _ _-
PROPERTY SS �'��
NAME �b,u�s�,� —
OWNER/ ADDRESS: %S�'IO / y��i y�'
TENANT -�7 'e � �+�/'�*/a /"r CITY ��i�l�v STATE%��ZfP 3..�
PHONE: /G,3� � Fi�'%` %�93
CONTRACTOR NAME /�ii�/��,,�� 1 r�dl d
SUBMIT A COPYOF ADDRES�.2 Z'%G Cci�o� '�- CITY_ S�. /"4 c.. I STATE %%�ZIP �.�/< <f
YOUR STATE
LICENSE W/TH PHONE G�J'GH3�-O� 2 Z_ Cr1.L r�FioN[ ______
APPLICAT/ON
STATE LIC t� STATE L30ND EXP DATC-.
1. Narrative/written description: 1 J J
� T �� S lY�I-I T ���N
b ,� � Gfd e► S',Sla��� c E I"u� « %i ri t �� / I'�
1���t -NriO �" o..�,�, �✓,r �..%! c�r.� fLwl i'�-s�f ac..u'<,.� �l;^c�.�, �ti.. �,i/7 rnea.n,
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations:
PERMIT TYPE
� SEWER CONNECTION PERMIT —' SEWER DISCONNECT PERMIT $50 __
I WATER CONNECTION PERMIT ' SEWER DISCONNECT PERMIT $50 _ _
�: WATER L1NE REPAIR $40
� SEWER LINE REPA[R $40 �- .�
I' ADD STATE SURCHARGE $5.00 for each permit �
_J SAC CHARGE @ $2100 =
i I �'��'"
TOTAL $ �, �'�'
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING
NEW WATER METER COST — SEE UTILITY B[LLING
SPECIAL ASSESSMENTS — SEE F[NANCE
WATER TAP — SEE ENGINEERING
NOTE: WATER METER REPAIR, INSP OR SHUT-OFF / EVENINGS, wcExrN�s & E�o�io�vs $125/HOUR-B[LLED
THIS IS AN APPLICATION FOR A PERMIT-NO"T VALID UNTIL PROCESSFD
I hereby apply for a water or sewer (new connection or repair) permit and 1 acknowledge that the information above is complete and
accurate; that the work wil! be in conformance with the ordinances and codes of the City of Fridley. 1 understand this is not a pennit but
only an application for a p mit nd work i t t tart without a permit.
SIGNATURE OF APPLICAN PRINT NAME: ��SSfP /il/�lYFtna H9 �AT�� /__r? �%`�G
�7 �-' �� �G3-2��i`:_ t'��5�5
APPROVED E3Y: t i�`V --� DATE: � Z��
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COPY GIVEN 'T-CS � UTILITY BILLING (only if new meter) l PUBLIC WORKS — ENGINEERING
City of N�ridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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