P - 35280Engineering WATER AND SEWER Permit No.:2� `Z� ,. V
763-572-3552 PERMIT APPLICATION Received By:���
,?Es3'S71-1287 fax CITY OF FRIDLEY e���_
EFFECTIVE O1/Ot/2011
APPLICATION DATE: � Zv 1� YOUR E-MAIL/FAX:
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
.IOB ADDRESS: i0 �2 � � r'+� � 'f'� � ,
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME: �%�V S�,pr�
ONA� ADDRESS: %�Z%�� %�''O✓� �ir C1TY ��vi��Q,e., STATE�"'ZIP �S`7�.�t
PHONE: /` �'° -r� � '�i �
CONTRACTOR NAME: +y�t-/ � T+� �-'`
SUBMIT A COPY OF �DRESS: �� 34/ Cc�. b�.�e� S�f , W� C�Ty /�/L►•�^Y►o �� $TATE 'h'7/LIP�
YOUR STATE
LICENSE WITH PHONE L/ Z� 7B/ - 3�"3� CELL PHONE: (y� 2- ?'Zl� �P(or''
APPLlCATlON
STATE LIC # STATE BOND: EXP DATE:
1. Narratix� wr�tten description: , ,
1Gc�.�c+� 5�.�� � �� �,�-*% Zs�.c. �-� '-� 4 3*� v�.h..� •
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations: ^ � C.J � ��� �
Z; ' _ �
� ' z
r2�-�.,e;C� g`7Z �-' 3 � �Z- •
PERMIT TYPE
C` SEWER CONNECTiON PERMIT t SEWER DISCONNECT PERMIT $50
I_' WATER CONNECTION PERMIT ( WA'i'�R DISCONNECT PERMIT $50
I WATER LtNE REPAIR $40
I SEWER L[NE REPAfR $40 U �
I: ADD STATE SURCHARGE $5.00 for each permit
I SAC CHARGE @ $2230 =
TOTAL $
�5 �
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING
_ NEW WATER METER COST - SEE UTILITY BILLING
SPECIAL ASSESSMENTS - SEE FINANCE
WATER TAP - SEE ENGINEERING
NOTE: WATER METER REPAIR, INSP OR SHUT-OFF / EVENINGS, WEEKENDS & HOLIDAYS $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTfL PROCESSED
I hereby apply for a water or sewer (new connection or repair) permit and I acknowledge that the information above is complete and
accurate; that the work will be in conformance with the ordinances and codes of the City of Fridtey. I understand this is not a permit but
only an application for a permit an� s not to start without a permit.
SIGNATURE OF APPLICANT PRINT NAME: �G ��h'` DATE: � Z6L��
APPROVED BY: DATE: � `� � �
COPY GIVEN �: I; UTILITY ILLING (only if new meter) l.i PUBLIC WORKS l� ENGINEERING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
__ ___
__
__ .
_ . _
. _ _ _ __ ._ _
,
_ _ �i- __ ___
,-�' _ _ . _ _ _
. �
0
��_ �,
l t� \ `
�
3 , �
� -v
�
�
II
__ .___