P - 48365Engineering WATER AND SEWER Permit No.: �
7�3-572-3552 PER,MIT APPLICATION Re�y By; .
`?63-571-1287 fax CITY OF FRIDLEY Dat�e I€ec'd ��V �
EFFECTI VE 01 /O l /2011
APPLICATION DATE: !�� / YOUR E-MAIL/FAX:
THIS APPL[CANT IS: ❑ OWNER I�d'�ONTRACTOR
JOB ADDRESS: %S�O I/aL.y �err.esl� S� ��/
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NaME: ,Ta",r c {�! e r f
OWNER/ ADDRESS: ?�00 �/Q�%f �K S� �y CITY ��"� ` �`eS STATE/N/VZIP�.�
TENANT PHOrrE: ?� 3 R� �� '�� 3 i
CONTRACTOR NAME: I� . � �r r�--��P
SUBMITA COPYOF ADDRESS: ?o L��
YOUR STATE �'� �� CITY S� a�C STATE��ZIP S'3���%
LICENSE WlTH PHONE �e!'"L�� Ya'f/� %-a- CELL PHONE:
APPLICATION STATE LIC #��0 ?���° ��4 STATE BOND: 46 /��6 EXP DATE: I� �r7oL ,
1. Narrative/written description: n r ' �
/� �F � 07� S'�-,� j�,� ' '� �e �'a� * r�i,�s �'�
�i b� c eLou.�.. Ca -e
2. Please attach sketch showing curb line, uti ity line, buildin etc. with distances on back page.
3. Stipulations: � � a �
. ` ) �
' i.v / � Y/��
i � �b3 Z3g $'0 8
PERMIT TYPE . ��(o � Z 3� gp
❑ SEWER CONNECTION PERMIT ❑ SEWER DISCONNECT PERMIT $50
❑ WAT'ER CONNECTION PERMIT �=; SEWER DISCONNECT PERMIT $50
❑ WATER L1NE REPAIR $40
�; SEWER LINE REPAIR $40 �
L ADD STATE SURCHARGE $5.00 for each permit
� SAC CHARGE @ $2230 = , '
f' O�
� TOTAL $ ; `i5 �^
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 SHlJT-OFF / EVENINGS, WEEKENDS & HOLIDAYS $125/�IOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VALiD UNTIL 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 w�f be in conformance with the ordinances and codes of the City of Fridley. I understand this is not a permit but
only an application for a permit and work is not to start without a permit.
SIGNATURE OF APPLICANT PR j�TJ�IAluIE: �� �4./`trgs2� DATE: ����G�
APPROVED BY: DATE: (O ' I � ` �
COPY C N � TILITY BILLING (only if new meter) ❑ PUBLIC WORKS :-� ENGINEERING
f itv nf Fririlev
- .. _ .,
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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