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Name �b�i� ���S'T�1 Z.��,
Date ��� ��
Old Meter Number � �1���
fJld Meter Reading �
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Replacement Reading �
Replacement Make
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� City af Fridley
Water Qepartment
6431 Universiiy Avenue NE
Fridfey,MN 55432
(763)572-3566
I/we hereby authorize the City of Fridley and/or its
employees to do what is necessary to replace the water meter. I under�tand that the property owner
is liable far the water line fram the main to the premise and all interior piumbing. (Per City code
402.06j 1 also hold the City of Fridley and/its employees harmless for any damages that may occur
while doing this operation. This to include,but not limited to;valves, piping,wails,floors or the curb
� stop box and service line. I understand 1 am also required to otitain a permit prior ta any work,if
necessary. _ � t .� '
final meter reading(ald meter� � �� � `�
Address• �f )��� ''�' � —
Name• . �—
Phone Number: . Date: ���� �
Signatare:
. Witness Signature:
FRIDLEY CtTY CODE
CHAPTER 402.WATER,STORM WATER,AND SANITARY SEWER
AdMINtSTRATIQN
(Ref Ord No 113,464,565,566,629,638, 662,922,488,1144, 1156�1191)
402.05. PERMIT FEE
Prior to constructing or repair of any water or sewer line cannecting the existing municipal system and any hause
or building for which the application is made,the owner or�ontractoi shall 6e required to obtain a permit for such
connection,and shall pay a permit fee as provided in Chapter 11 of this Code. After such connection has been
made,the Water and Sewer Department sha11 be notified. ft shaA be unlawful to cover any connecting line until an
inspection has been made and such connection and the work incident thereto has been approved by the City as a
proper and suitable connection.
402.06.REPAIRS AND MAtNTENANC�TO CONNECTtON
ARer the initial connection has been made to the water service curb stop box or the sewer(ead at the property
line or a water service or sewer lead has been extended to the property line for connection,the applicant,owner,
or the occupant or user of such premises sha11 be liable for all repa�rs required to any water(ine and sewer lines
necessary for cannection of the premises from the main to the premises. tf the property owner requests
mai�tenance service or repairs be performed by the City,the praperty owner sha(I be charged for the costs of the
maintenance and/or repairs, including any�ecessary street repairs,at a rate set annually by an administrative
policy. It shall be the responsibility of the appticant,owner,occupant ar user to perform standard maintenance of
the sewer service line from the premises to the main including debris clearing o�root cutting and to maintain the
water service curb stop box for operability and at such height as will ensure that it remains above the flnished
grade of the land or property. (Ref 638,1156, 1191)