P - 48145�uilding
Inspections
763-572-3604
763-502-4977 FAX
DATE � `�`. " � `f � t I �
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EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
Permit No.:
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SITE ADDRESS (�o1.3I .St�" CSt• l� � �� c vl s�, Q-{ a
THIS APPLICANT IS: � OWNER �ONTRACTOR �
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
_ PERNIIT TYPE
M r'� � �[�] a`.�I���;f
NAME: �,lObt-rDl� I�(D-�
ADDRESS:_�ol� 5�'�' .�t�. ,v � CITY�i4 t 0/�, STATEHN ZIP
PHONE: �6�� �'�f3- �C?� �
NAME: �Vt V C(.� IP (l.�rt%t•-, 4r
STATE LICENSE # EXP DATE
STATE BOND # EXP DATE
ADDRESS: ��q � h'i0-�-� 5� N� CITY �K-�✓�i� STATE M� ZIP S5 `f3.L
PHONE �7 C3 �% S �F c�- ��1 i gA,y
`�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
� TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
L���ti�,
FEES ARE BASID ON $10.00 PER FIXTURE, EXCEPT Wi�RE NOTED. FIXTURES: (INDICATE TOTAL NUMBER'OF EACH BELOVI�. bID1IMUM FEE
$35.50. '
BATH SINK/LAV FLOORDRAINS SHOWER
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL
CLOTI�S WASHER KTTCf�N SINK WATER CLOSET
_ DISHWASHER _ LAUNDRY TRAY �WATEIt HEATER ($35)
_ WATER METER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROC�SSED
WATEREIPING
WATERSOFTNER ($3�.
BACKFLOW PREV. ($15�
FOR IRRIGATION
_ OTI�R
I hereby apply for a plumbing permit and I acicnowledge that the informafion above is complete and accurate; that the worlc will be in
conformance with the ordinances an codes of the City of Fridley and with tlie Minnesota Construction Codes; that I understand this is
not a permit but only an applicatio fo rmit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the c of al� w c wI �ich requires review and appr�?val of pl
SIGNATURE OP APPLICANT ��^� 7 PRINT NAM� 1...� �' �°� �,7o DATE 1 a-' < <
APPROVAL INSPECi'ORS SIGNA'PUR� i ' DATL�!`��
�l�' 4� �'3'�C��B�
�ui�ding �nspe��ions �epa�flnent
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FA�Y: 763-� 02-�977