P - 42332From: 7635193932 Page: 4/5 Date: 4l28l2010 2:38:40 PM
Building 1'LU1V�IN+� ��'�'�t ��. �
Inspections C(;N.[M��G�,L ,AP�'�YCA'�ION ���"�ceive
�'63-5'i2-3f (14 ��ahe�t.e'c'd: � 11 I O
���-so��a��� �,� CITY (J� k'�IDL�E�i'
�FFEC'Z7YE 1-I-2QI0
�3.t#� �'�r� �.°a - i O YQUR �MAIL ADDRESS � tle, l) c. L O��i�.Gs tn� `f � 1�' S�: C�tv't
St�,�z���ss �: 7 C7 c� v,.�. S"
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PRU�E��x IVAMA� �..i irl��t+��
Q�� ADDRE33: f� eZ C� � U� ��c� � Y� t�� �I�1' �li'c c� l�+! STA7'E��IP�� �� I
'Y'�NAlY'I' pk�fO(YE� `'7lr� ,�i � "� 7 I —�7 � �
C0�1�AC'�'OR Ne�M]E; r> ��: � y G ca
st7��tT A co�x a� sznr� z�xc�rs� # c"? ���`�f !° i?/.t . ���� !� r 3 i- Ib
xavz� sx'a�
z.�c�xs�, sorn� .�t� �z.un�zrr� �orro � ! c� j {'�# �--�,-a � � �xx �n� � � � � ! � 1v
CERTIFTCATE QF apDZ�ss: �� 5 3� �?-r{� A � e�tl v cmr � `�-G. s�nax �_NznP ��f 7
rarsu�,wcE PHONE �7 � � -- ss � - 3 � �a a. `
�. ��.x '7 r�� - �/ g - 3 �i 3 �. , ,
PERMIT TYPT ❑ IIV3TITCt7TONAL �tatv�.7'�-��.n�.X ❑ swi�N� Pooe.
O 'f4Wri�i0USE �7 CO��LCJI.A�LIJ�3AUS�L 0 OrHSR
�rx�� r�� woaeu�• � z'�w ye(�.e�c�Errr Q ALTEItAT10N/REMQDEL
� � _ � r1
DETAZL�D AESCR�'TION OF WORK ��.� ����- �,... ^tiC,i'+�2.e."E" � i d-� tM �`� � v- V a t u-e� �
FFX"liJ�i,�3: (�IV�J(CA'10E 7'OTAL N�U'iv�I3ER OF EAC�
_ca.on�swasr,�x _FLOORnxAUVS _�zvna.,v� �u�.nvna.
_ DISFiWASi�R _ GAS PIP7NCs BACK�i.OW PR�'V. ,,,,, WA'�R �EA'IEIL
_ D�N�ING P�UNCA,xN _ GREASE �tAP ._ TlOOF DRAtN3 ., WATER. ME1"ER
F.AUCET _xS;�C`�1 STxt�C. ,,,,_, SHOWEit I" �R►ATERPIPING
FLAHA4ABLE WASTE TRNK _ I.AUN,P�iX'fR,A,X , SL4P $tNJC _ WATEk SOF�PIER
_�.A,YA,TO�Y ,�,,,_ SWiMNf[NG P001. _ WATER CtOS�x
Total Job $�� p,All fees ara based on valus�ion� including the cost af labor and materis)s.
Valuat�am
Pern7fi Fee � `�5 `'�C7 (�.�59�'0 o�JOb Va�nat3on / M3lnirte�un fr.� S35)
Surchsrge $ �ad Valuation X .0005 or �iuniunu�a .50
'�dtsl Due $ �'SO Iv�ake Ct,tecks Payable to: Clty of Ftfdley
THIS 1S AN APPL1CA170N FOR A PERMiT NOT YAWD IJld71L ,P�tDG�SS�JJ �
Z b�eby a��y for a ptw�nbing pe�atit a�ad � acic�tawledge tt�ai the informua�ion above is compi� and accurate; that �e wo�k wi�lI 6e in
confiOrn�nce with the ordinances end codcs of thc Ciiy of �ridley and with the Minncsata Comsirx�ciion Codes; that I undastarid this is
not a pea�ut but �ly an applic�tion fa a permit and wo,rtc is not to sta�t wtthosti a pertttit On s't�e; that ihe wark will bc in acr.otdance
�with th� appraved plan in the case of all work which requires rcview and approvat of plans. �
tvn� a� n��.xcarr� ,� � �. L v�n � r. d S 4�� I- I'� nA� �I --�1 s- r L>
SIGNATtlRE OF APPLICANT
�X.�,A.S� NO'�: SF.�ARATE PERMTTS ARE RE UiRED F�R �UT1.17TT1VG, �i.ECTRICAI. AND MECFIANiCAL WORK
�City o��+'ridley Buitding �nspections DeparEment
6431 Univexsity Avenue NE, Fridley, N�1 SS432
763-5']2-3604 F�►X:763-SQ2-4977