Untitled No 588
CITY OF FRIDLEY , 6 C_')
PUBLIC WORKS DEPARTMENT Date
TAPPING APPLICATION AND PERMIT
FOR INSTALLATION OF WATER&SEWER SERVICE
I) This form to be completed before a tap is made to any existing water or
sewer line.
Lot S9 Block ddition LLrKC, 4-Aef
Address �/ 5 .C osv i L116-k-)
Owner
Plumber / / `./ y 4
CHARGES TO BE,PAID BEFORE TAP IS MADE — WHERE
ASSESSMENT HAS NOT BEEN LEVIED AGAINST PROPERTY
II) Water&sewer connection permit must be registered before this Tapping
Permit can be issued.
City supplies all material and labor for 1" or under water tap. Con-
tractor supplies all material and labor for water tap over 1", and all
sewer taps.
WATER TAP: Materials Used: $ �"� C)�
Street Patch: x $
$ X=XXXXXXX_XX XXXX
SEWER TAP: Street Patch: x : $
III) If this property has not paid a full Lateral Charge for its share of the
water and sewer system, additional charges will be placed against it.
This will be in addition to the normal connection and tapping permits,
meter deposits,etc.
TOTAL $
Water
ASSESSMENTS TO BE LEVIED: Lateral: $
Sewer Lateral: $
TOTAL ASSESSMENT:
Clerks Signature
Supt.of Public Works
M/P 3/76 White P.W. CanaryFinance Pink Prop.Owner Goldenrod Plumber
Rom
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