p - 42153From: 763 754 0066 Page: 1/1 Date: 3/11/2011 2:59:55 PM
Suilding �I,jJnejBIj�j(i Permit A1o.:
Inspections ICONIlVIERCIAL APPLICATIQN Received By:���l, --.--
763-572-3604 �ITY UF FRIDLEY �ate :� �-�
763-502-4977 FAX ��
EFFECTIVE 1-1-2011.
DA"� '�y -E'��� VOURE�MAILADURESS ��1.i�7�'1�'C.�'�y�;(��'1iSi'vt�kl�rr:Mvfli t(.}�^!t
SITE ADDRESS S t'CC� C� .� `� Sj" �11� ��
�nrrr � cJ � I 1 S-i�� d su�TE xa. ._._._._—.____...._..—
PROPERTY NAME: �Ci �� �`f} �$1�'..
TENANT� ADDRESS: G��C7f.i �J'r•� C"I" ililr C�7Y � t'�. Tt STATEt"ttJZTP
PMOI+iE:
CONTRAC7�OR NA:�IE: ' ����r
SUBMfT A COPY �F S.fATE LtCENSE t� C�L•� l k' .�, 'a- P,M EXP DA'fE �J I L �
YUUR STATE � -
LICEI�SE, x�� .�wn PLUMB ING BONII # � l� c; ci �J 7 p r� Li � D.a-rE �.�.I-� I,/, 1 l
CERTIFICATE OF ADDRESS:---p�.C'��I I d� �' ?QC���. I'�W CI'fY i:. � �' STA7'�'l�' ZLP ��
INSURANCE PHONB '{ lC�'✓' 1 S�' ' Oc� o
t Gi F�x �"3 _ S k—vG�� tc
PERMIT TYPE Q�ST[TU7'lONAL 18'MULTI-FAM[LY i1 SWIMMTNG pOOL
CJ TOWNHOUSE ❑ CQ�iMERCIAL/INDUSTRIAL ❑ QTHE1i
�rE o� wow�: Q N� �R�C��T � ALTERATION/REMOD6L
DETAI%ED DESCRIP'TION OF WORK .�.. 1S� �j`,� �' �
t'U � r'l 1Y . ,
FIX7URL•S: (INDICA7E TOTAL NUMBER pF fiACH)
_CIATHES WASHER FLOORDRAiNS �RPZ VALVE URINAL
_ DIS}EWASHER , GAS PtPDJ(3 BACKFLOVN PREY. � WATER HEATER
_ DRIlVKING FOIl1VTAIN `GREASE TRAP � ROOF DRA1N5 _ WATIIt M&TER
FAUCE'i' _ K1TCF�N SINK _ SHOWER _ WATER PIPING
FLAMMABLE WASTE TANK _ LAUNQRY 7RAY _SLOP SIMK _ WATER SOFfENfiR
_ LAVATORY _ S WINIl�IING PppL _ WA'1'ER CLOSET
Total Job $ �� l� AIl fees are based on valuation, including the oost of labor and �terials.
Valaa6on
Per�r►rt Fae $ ��� (1,25%ofJob ValuatioTC / Minimum fee; �35)
Surc�'8e $___� i�?.� �'aluation X.40�5 ar Lvrnimum .50
,�7 �S�
Total Due $- I��"'� Malce Chectcs Payable to: City of Fridley
77iI3 [5 AN APPL[CA77pN FOR A PERMIT-1VQT YALID UNTIL PROCESSLD
I heneby apply for a plurnbing permit and t acknowkedge rhat ttie information abave is complet� and accw�ate; that tf�e work will be itt
conformance with the ordinances and vodes of the City of Fridley and with the M"mnesota Construction Codes; tlta�t i understacEd this is
nat a pertnit but only an application for a permit and work is not to start without a permit on site; that the work will be in accordanve
wiih the approved plan in the case of all woxk which requires review and approvai of plans,
SIGNATURE OF APPL[CANT : PRIiVT NAME: tu G4�L �� L� � � YJ t''�� AA7E: J'� ��-' ��
APPROVAI, INSpECTUR SIGNATIIRE: � DA • '� 1•'
PLEASE NOTE: SEPP.RATE PE ITS RE UIRED FOR BUII.DING, ELECTRICAL AND MECHANi AF. WORK
City d y Buildiag Inspections Depart�uent
6431 University Avenue NE, Fridley, MN SS432
7b3-�72-3604 FAX:763»502�977