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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 understatid
that the property owner is liable for the water li.ne 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.
� _ �
Name: ��tko� �� Address: -So 71 cl e�z �Q.n,� �E•
Phone Number: �6� -'�l�•,� aa Date: �I� 1a-11
Y n�
Signature: �e�� `�'�
Witness Signature:
FRIDLEY CITY CODE
CHAPTER 402.WATER,STORM WATER AND SA�IVITARY SEWER
ADMIlVISTRATIQN
(Ref Ord No 113,464,565,566,629,638,662,922,988, 1144, 1156,1191)
402.05. PERNIIT FEE '
Prior to constructing or repair of any water ar sewer line connecting the existing municipal systena and any
house or building for which the application is made,the owner or cantractor shall be required to obtain a
permit for such connection,and shall pay a penmit fee as provided in Chapter 11 of this Code. After such
connection has been made,the Water and Sewer Deparbment slYall be norified. It shall be unlawful to cover
any connecting li.ne until an inspection has been made and such connection and the work incident thereto
has been approved by the City as a proper and srritable connection.
402.06. REPAIRS AND MAiNTENANCE TO CONNECTIUN
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 lia.ble for all repairs required to any
water li.ne 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 properiy owner
shall be charged for the costs of the maintenance and/or 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 mainxain the water service curb stop box for operability and at such
height as witt ensure that it remains above the finished grade of the laud or property: (Ref 638, 1156, 1191 j
€�e�qUest for,�erviEc:� R�p�rt
�ity of Fridley
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1kl�esa� 5QT2 Tt3PPER Lf� NE ae�c Rha�e: 763-3�0-�4
Seh�ed [l�e. ��'l�{'l� ��:' � � �t;roPrn Fr�yC)wner:
1:,�c�ior�[�t�ls: ""B�L� Request D�etails: Stat w�er aff
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Reque�t farr Serv�t� R�port
City af Frid�y
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[�partment: W�er Gtizen N�ne: SHAhJP+K}tV STC7NE
Addr�s� 50T�TUPPER LM NE ac�c Phv�e: fi1'2-�2��88
Sctredt#ed [}ate: Ptnperiy Uwner:
Loea�ion C3eta�s: �hanncui no k�ge�has access tc�home. F�equest Detail�: SFxf�rater df-fa�re�dam�re
Please shu�rvater c�f. This i�a fa�re�do�.
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