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fWDLEY
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Request for Se� Rep�rt
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Address� 54i15 4TH ST P!E Ca(�acic Phvne: 763�-�3&49�08
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Loeati�an C7e�ails: Permrt##2(711-079�2 � DetaiFs_ Slx# water off/I�a�k�r
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City of Fridley
Water Department
6431 University Avenue NE
Fridley MN 55432
(763) 572-3561
Uwe hereby authorize the City of Fridley and/or its
employees to do what is necessary to shut off the water at the curb stop box. I understarid
that the property owner is liable for the water line from the main to the premise. (Per
City code 402.06) I also hold the City of Fridley and/or its employees harmless for any
damages that may occur while doing this operation. This to include, but not limited to,
sod, yard,landscaping, trees, shrubs, driveways, sidewalks or the curb stop box and
service line. I understand I am also required to obtain a permit prior to any work.
Na.me: Address:
Phone Number: Date:
Signature:
Witness Signature: ,. `
FRIDLEY CITY CODE
CHAPTER 402.WATER,STORM WATER AND SAIVITARY SEWER
ADMiNISTRATION
(Ref Ord No 113,464,565,566,629,638,662,922,988, 1144, 1156, 1191)
402.05. PERNIlT FEE
Prior to constructing or repair of any water or sewer line connecting the existing municipal system and any
house or building for which the application is made,the owner or contractor shall be required to obtam a
permit for such connection,and shall pay a permit fee as provided in Chapter 11 of this Code. After such
connecrion has been made,the Water and Sewer Department shall be notified. It shall be unlawful to cover
any connecting line until an inspection has been made and such connecrion and the work incident thereto
has been approved by the City as a proper and suitable connection.
402.06. REPAIl2S AND MAINTENANCE TO CONNECTION
After the initial connection has been made to the water service curb stop box or the sewer lead 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 shall be liable for all repairs required to any
water line and any sewer lines necessary for connection of the premises from the main to the premises. If
the property owner requests maintenance services or repairs be performed by the City,the property owner
shall be charged for the costs of the maintenance andlor repairs,including any necessary street repairs,at a
rate set annually by an administrative policy. It shall be the responsibility of the applicant,owner, occupant
or user to perform standard maintenance of the sewer service line fram the premises to the main including
debris clearing or 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 finished grade ofthe land or property. (Ref b38, 1156, 1191)
� ` Req�st for Ser�ioe Repart
City af Fridley
��r�: s�i-��-�� a��: 7 trsr�t�
Request T�re� �#au AMR�eter Ent�reci By: W�dy#��t
Departm�t: Water C�izen Narne: Ga1&�soJcs
Adctess� a�615 4TH ST NE ac�c P#�cme: 763-ar31''-0162
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