P - 80967Engineering WATER AND SEWER PermitNo.: �����,; �' �
763-572-3552 PERMIT APPLICATION Received By:
763-571-1287 fax CITY OF FRIDLEY Date Rec'd:4-1a-1.2
EFFECTIVE O1/12/2012
APPLICATION DATE: 4'�b-Zei L YOUR E-MAIL/FAX: �'+r"�h Q lb��w ►+ w►L.`��.-.
THIS APPLICANT IS: ❑ OWNER ,�'CONTRACTOR
JOB ADDRESS: (�ONp wpq�ka.� L,�.> c:,
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME: 1.aJ�n.1��� t,..p�,..�....�
OWNER/ ADDRESS: �ONO Lc�aerF�, (,a,•.+C CITY ���DIO ( STATEM�IZIP SS�l
TENANT
PHONE:
CONTRACTOR NAME: Nev� ►w h �ct..�a.�.+ts. �- G� re-c�.te--�sr $
SUBMITACOPYOF ADDRESS:36S0 (Lcv..�w6�c c!1 CITY G�G-�J STATE��ZIP SSra�
YOUR STATE
LICENSE WITH PHONE 6S I-l$4 -�S7 f CELL PHONE: _(S I-6G�c' (�3SS _`-��
APPLICATION
STATE LIC #�Ce %j�''OS3 S STATE BOND: EXP DATE: � Z'3 �°��3
1. Will work take place in City ROW? Yes � If yes, ROW registration is required — see Engineering.
2. Provide written description of proposed work: '�p.w,r- c'' ��,.,� �,..;," f„ �,,,�
�G �--T �-(�'. +�
3. Attach plan/sketch showing proposed work with existing curb, utilities, trees, buildings, etc. with dimensions
4. Circle type of erosion control measures to be installed to prevent disturbed soils from eroding:
Silt Fence Bio-rolls _.� Erosion Blanket Sodding Other:
5. Provide minimum of 2 hr notice for inspection ( 8 am — 4:30 pm) and call in the following order: (763) 572-
3552, (763) 572-3556, (763) 238-8058, (763) 572-3562 or (763) 572-3551, or (763) 427-1212.
6. Refer to "Construction Requirements for Water and Sewer Work" on back of page.
7. Stipulations: ° - ' ` '� _
PERMIT TYPE
C SEWER CONNECTION PERNfIT ❑ SEWER DISCONNECT PERNIIT $50
❑ WATER CONNECTION PERMIT ❑ WATER DISCONNECT PERMIT $50
�' SEWER LINE REPAIR ❑ WATER LINE REPAIR $40 �{a�
❑ ADD STATE SURCHARGE $5.00 for each permit S'i°
❑ SAC CHARGE @ $2365 =
TOTAL $ �tS °°
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-0FF / EVENINGS, wEExEtvDS & xoLIDavs $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a water or sewer 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 Fridley. I understand this is not a permit but only an application for a permit and
work is not to start without city approval of this permit application, unless emergency repair is required.
SIGNATURE OF APPLICANT/ /� L�-- PRINT NAME: �3 'A -i'�^�+-1 DATE: N-w •La �t
'.+:_.' -,.�,,.._,�.,...,,._. _ ' . - f. , __ „ .ir'
APPROVED BY: � . , , �.... DATE: �' : �.
COPY GIVEN TO: ❑ UTILITY BILLING (only if new meter) ❑ PUBLIC WORKS ❑ ENGINEERING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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