P - 48306Building j��,�J�$�N�i Permit No.: ��Vi/� F,�,
Inspections 12�S���i j�,T'���,�, ���j�I�;�4,�'IDN Received By:�
763-572-3604 ���� �� ����.��r Dyte R�e��
763-�02-4977 FAX EFPF:CTIVE 1-1-201? f' -
DATE o�a'�_�� YOIJR E-MAIL ADDRESS
SITEADDRESS ,5�.9 �i� �" RVt NFs ��a(
THIS APPLICANT IS: O OWNER �ONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
II+ISURANC�
PERNIIT TYPE
�rE oF woxx:
NAME:�d�n I �Pt �0��✓i
ADDRESS: 5 a9 S� �k 1Q V'L �"� � CITY �iQ„l d tt�. STATB'1ti ZIP tS3 Yz1
PHONE: �oS( " 01. g3� �E 3 q 3
NAME: VL�..s
STATE LICENSE #
EXP DATE
STATE BOND # EXP DATE
ADDRESS: Bei-R� T� b-1.. C?'� N� CITY F�Oi�.i STATE �"'« ZIPSJ���--
PHONE �% '�e3 7 S�f' J'� 4 q FAX
�INGLE FAMILY
❑ NEW
❑ TWO FAMILY ❑ TOWNHOUSE
DETAILED DESCRIPTION OF WORK �,� S�A ( I%�.i.��p I�•-�-�-1 v+.�.�, C.��►�;+- �Lr��-
FEES ARE BASED ON $] 0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET _ BACKFLOW PREV. ($15)
DISHWASHER LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; that the work will be in
confor►nance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application f r a permit and work is not to start without a permit on site; that the wark will be in accordance
with the approved plan in the(� e of al or iich requires review and approval of plans. �1
SIGNATURE OF APPLICANT L(i-�L.�O PRINT NAME C� (ti rw Io p'P DATE O�'J' a� 1�—
APPROVAL INSPECTORS SIGNATURE DATE
� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977