P - 42194Building
Inspections
763-572-3604
763-502-497? FAX
DATE � 'r
53TE ADDRFSS �
i'I-D3 APPLiCANT 1S:
PROPERTY
OWNER!
TENAN�'
CONTRACTOR
scnan�nr A co� oF
YOUR STA'1'E
LICENSE, BOND AND
CERTIFIGATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
From: 763 754 0066 Page: 2/2 Date: 4/14/2011 8:37:10 AM
P�UMBING
RESIDENTiAL APPLICATION
CI'�'Y OF FRIDLEY
Permit No.
. . - . : ��•pt��'
_ `
� �� , �� ;
r. i=��` - ��.
� � , YOURE-ivfAILADDRESS �(1�GtJ1Cdi U"l�,�t1v�C�Q ���`3'�I /1Gr(✓S� � G� �\/j
� �r�� � � --
o awx�x HCONTRA(,"I'OR
Na�: �C�l� ��GUJ�E_
,�a�ss: u�a�, ��� s'-� N� ��� �� a t� STATEI'IA � ZIi' S�a 1
PHONE:
STATE LIC�NSB �t ��� P 3 a- f�,-.. EXP DATE � a-- � 1-1 t
STA'CB BOND #_(� 15 d D"11 �� ='� FXp pqTE �- 3 l- t 1
ADDRESS; a�S� ��� rt ���in� CITY �iti•1 �7l a.I STATEj�Q'/�_2IP SSN�i
PHONE `Q`a�- a��''�� ��� FAX �1n�-�s'�'�—UUio C.n
L�7 SIIVGLE FAMILY
� NER'
DETAILED DESCRIPTION OF WC)RK
Cl "�WO FAM[LY CJ TpWNF�OUSE
9 REPLACEMENT
FE65 ARE BA3ED ON 510.00 PER PIXTURE, EXCEPT WEI�RE NOTED_ F[XIURES� (INDICA'CE TOTA[. NiJMBER OF EACH BELOVV�. I�QN�vItJM FEE
535.50.
BATi�I S1NKlLAY FLOOR DRAIh15 SHOWER WATER P[PING
BAFHTUB GAS PIPINC3 (N�ED CITY LEG7 ^ SWIMMING POOL � WATER S�F7'NER (335)
_ CLOTE�S WASiiIIt _ KITCNEN SINK WATER CLpS$T _,,,_BACKFLOW PREV. ($15)
_ DI3HWASHhR _ LAUNDRY TRAY �WATElt HEA7'ER {$35) FdR IitRIGATION
_ WATER l��TER „_„_ UTHER
Number offixtares (a7 $1D.00 X $10.00 = �
Namber of fixt�rres �� 15.00 x$15.00 = S
Number of fixtures aQ �3S.W � x$3S.U0 � S�`�J' . � C�
5tate Surc6arge
3 S.OQ
=S ��' ��
THIS IS AN APPLICAT[ON FdR A PERMIT-TiOT VALID UNT1L PR.00ESSED
I hereby appEy for a ptumbing permit and � knowl that the infarmation above is c�np�ete and accurabe; that 13�e work wip be in
conformance wi� the ordinances and codes o the of Fridiey and with the �iinnasota Construction Codes; that I understand this is
nat a pemrit but only an application for a pe it work is nvt to stazt without a permit on site; that the work wili be in accordance
with the approved plan in the case of all work �+equires review and approval of plans;
SIGNAIURE OF AE�LICANT PRINT NA1V1E��.�",�k'1 SC�I t I� �f".S'"� DA'TE �'I.'�� '" (
APPROVAL IPiSPECTORS SiGNATCJ[t� TDA7'E
PI�EAS� NOi`E: SEFARATE PER11qt REQ D FOR BUII..DII�IG, ELECTRICAL ATiD MEC cAL woRK
City of �ridley
Building Inspections Department
6431 University Avenue NE, Fridley, MIV 55432
763-572-3604
PAX: 763-502-4977