P - 48649Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �v ��✓ ( �
SI1'E ADDRESS _�,�„
THIS APPLICANT IS:
PROPERTY
0�4'1�IEi2/
TENANT
��������
�E�g��I�T'�'�� A������'�'��I�
�.��� ��' ������
F.FFECTIVE 7-1-2010 _
YOUR E-MAIL ADDRESS
❑ OWNER �CONTRACTOR
Permit No.�G �� �-��'
Received By:
��wi��-�'--,'�-�
CONTR.�C"I"OR NAME:
SUBMIT A COPY OF STATE LICENSE # # 6177i1—PM EXP DATE
YOURSTATE
LICENSE, BOND AND STATE BOND # 651-365-1340 EJ�T DATE
CERTIFICATE OF �Dx�ss: 3670 Dodd Rd. cITY STATE Z1P
INSURANCE PHONE a9an� FAX
PEIt1VIIT TYPE
TYPE OF WORK:
�INGLE FAMILY
����
DETAILED DESCRIPTION OF WORK
❑ TWO FAMTLY ❑ TOWNHOUSE
C�PLACENJENT
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTTJRES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/f.AV _FLOOR DRAINS SHOWER _ WATER PiPING
Bq'IT3TCTg GAS PIPING (NEED CITY LIC) SWIIvII��TG POOL _ WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SIlVK WATER CLOSET _ BACKFLOW PREV. ($1�)
DISHWASHER LAUNDRY TRAY �WATER HEATER ($35) FOR IItRIGATION
— WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII. PROCESSED
I hereby apply for a plumbin; permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance 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 for a permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case of all which requ' s re ' w and app of lans 3^ ZL_ ( y
SIGNATURE OF APPLICANT A ��1 S c�� DATE
APPROVAL INSPECTORS SIGNATURE
PLEASENOTE:.`SEPARAT TS ARE REQ OR BLTILDING, ELECTRICAI, AND 1VIECHAIJICAL WORK
�1�' 0� ��'l���y
�3u�ldang Inspeetnons Departme�t
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
�