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i�'�;ve hereby aaz�horize t�ae�t�j a��ridtey artcJp'or its�a�ap8a�ees to do�vd�at�s�secessary
r��tace�se�ater rneter, ��r���rs�and that the�ar��oer�y ownea��s dia�le far t�ae water#ine fram 3fie maiea ta�he}�rereaise and al1�e�terior
��uraalbinge {Per�C6t��casle 4�c.�fl6� �aism�soicfl tiae�"rt�y af Fr�dley aracd,�iLs empirsyees harsnless f�r arry da�eages�lhat a�s�ay occur wlaite doing fi
��er�t9an. 7hds tm include,�ae�t�ac�t iimitesd Yo vaives,pipin��ratds,�lcors flr�e cur�stap�ox aad serarice 9irte, �n uesderstand�asza alsa�ac
�o o�atain a�enm�t�arnorto arae��rortc,if necessary.
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Name• � Address _��� ( �1�,���, �j�.
Ptso�e�dumber � ���-��-�— i�ate �" l q„' r r"�
Signatur� bVe�ness Signature
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4��,5 PE�tNIi�'FEE
� Praar te cortstnuc�;ing ar��vair�f any water of se�►er line connecting�e existing 3nunaci�sal syst�m and arty house or buifding#ar whid�t tlye
a�aplication is made,the ovvner ar�ar�traactor shall�se requiced t�abtain a permit�or such conrtection,and shail pay a permit fee as provided
�hapt�r 11 of this Code. After such cortrtection has�aeen made,the'�Iafier and Seuver�e�artmerrt shal(be nutefied. It shali be acralawfu�to cc
any�oranecting line ur�tdt art ins�ectian has been made and such coa�r�ectian and�ee�e�ror(c incideist tt►ereto has I�een approaed tay the C'rty as;
proper and suitab(e sonnection.
�LOZ.06 3tEPAiEiS At�1D�UtA6NTEfVANCE���{VIUECTION
,a,fter tfee 9nitdai sonnection�as been macle to�e kvater service cmrb stop�ox or the sevver(ead at Cfie property line or a water�ervica(ead h:
been extended to tfse property line for conrtection,the a�splicarrt,awrter,or occuparrt or�ser�F such premises shall(te liabt�for atl repairs
required to amf water line and sewer(ines necessary Por connection of t€ze premises from the main to the premise�. if the property oarner
requests mairrtenan+ce senrice or repairs be perfasmed by the�'3ty,the proper�y owner shall be charged for the costs of the mairttenance aad�
re�airs,including necessary street repairs at�rate set annuaity�iy an administrafiive poiicy. It shai(6e the responsibitity af the agplicarst,
awner,occupant or user to q�erfarrn standard mairrtenance mf tf�e sewer service�icse from the�Sremises to the main indud'ang debris clearing fl�
r�o��utting and to maintain the uoater service curb stop box for operabidrty and at such height as+Nilt ensure that it remains af0ove,�<�{nishe
grade nf the tand or properl.y. {etef 538,�..lS6,119�) �k�-
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REQUEST FOR SERVICE REPORT
CITY OF FRIDLEY
Reference No. ��nd� Date: C�—
` � � ��
Request Type: Entered By:
Department: Citizen Name:
Address: °��"�7 ��,"�"�(-�.�� Phone Number:
Scheduled Date: Property Owner: -
Location Details: Request Details:
Action Taken:
�:;� 1 N�Z4�C. .�.tZ
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Responsible Person:
Approver:
Completion Date: �� � t�..�- � "� Citizen Noti�ed: