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REQUEST FOR SERVICE FtEPORT
CITY OF FRIDLEY
Reference No. ''70�� Date: q� ��.,_��
1
Request Type: Entered By:
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� Department: Cititen Name:
Address: �� �j(„�jJ C'R�� Phone Number:
Scheduled Date: Property Owner:
Location Details: Request Details:
' Action Taken:
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Responsible Person:
Approver:
Completion Date: '�, �� �l""1 Citizen Notified:
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���'r� here�aa.athorize the�fiy a€�ridiey andJar its�arepia�ees to do yvE�at is�ecessary
�'��aac��e'nrat�r me�t�r, ��anderstana�that#d�e�e�ope���uvnea�as�iable far xi9e yvrater line fr�arta the nnadra to the prQmise snd a1t�e�tsr4or
�iasa�abirsga �Per�iiS++�cae�e 4��.�D6� 9 aJs�#sol�t ti�ae�'rty fff�r�diey asadJits empia�yaes fiarsnless for ar�y dara�ages�at�rnay ocaar white doie�g t
��ee-�tion. �es to incterde,�as�t sac�t timrtes!�im vaives,�fpica��iis,filoors flr�e airi�stap�eox and service 1ine. (n undeastand t arn afso r�c
��o�etain��ee�rrait�rnortc�aray w�rEc,'sf necessary.
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'�ig�`��� W�ness Signature
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4CD2.5 P�E�tMiT�EE `
� Prior to corstr�acting or reoair�F any�vater of;zwer lins connecting the existing muntcipal system and arry house nr bu�:$or.which the
a�sgslication is rnade,the o�rner ar�orttractor shaii be required to abtain a permi�for such cannection,and shaN pay a per�t`:fee as provided
�hapt�r 11 of this Code. Aftsr such co�r�ection has been made,the iNater and Sew+er Departmerrt shai{be notified, !t shaid be unfaivfu(to cc
an,y coranecting(ine untid�n insp�ction has been made and such connectioa and the�,voric inciderrt tt�ereto has beert a�pr�ov�d fry tfte City as;
�Sroper and suitab�e cartraectiort.
�02.06 �2EPA�RS APtD MAiN'B�ENANCE Tt�COPlNEC17QN
After Lhe inifiiai connectton has been made fio t�e+�rater service�urb stap box ar the sewer iead at the praperty line or a water service lead h:
been ex�tended to tiie�rvges7y iine For sannection,the appli+car�t,aznrner,ar occuparrt ar user of sLrch premises shall Ite liable for ait repairs
required to any water line and seuver lines rtecessar�for connection of the premises from the main ta the premises. tf the properCy owner
requests mairnenance senrice�r repairs be perFormed by the Crty,the property awner shatl be charged for the casts af the maintenance and�
re�airs,including raecessary street repairs�t a rafie set annuatty�y an administrative poiicy. tt shatf be the respocisibifity of the app(icarrt,
owner,occupant or user to perForm s�andar�i mairrtenance of�he sewer service line frvrr�the premises to the main induding debris dearirtg a
r�ot�utting ar►d to maimain the+,vater;erv�ce curla sto�box for og�erabitity and at such height as witi ensure+that it r�mair�s above the finishe
grade of fihe lanct or pr�perC�- �Ref 638,Z1S6,1191j