P - 48336Bui�din� i ��,.������i � Permit No.:l�ii�1 ��f(,� �� ��
111S�eCtl012S � ��t ����,�T�'��� ����,���,������ Received By:/ � F+I�' ���'
76 � >7?-3604 ���'�j �� '� ��►���j I Dat���d�� �« i�a � �� �'' 41 ��:
7E � 50�-4�77 FA�i err�t-cTivr. �-� �o�� !
���r�: � - .:� �, _ ,r .�
SITL ADDKESS
THIS APPLICANT IS_
�ROp�Riz'
OWNER/
TENANT
vour r�-Nt���__ n��a�ss
❑ OWNER �CONTP.A�TOR
N a M [: � ' �1 r- t-� `. £ . � > � > • i _.� r_:• . 1 '.
n�uR�ss %�-6 1 S c-� � �, r: ciT� _,��, f s� nTr ^'� r zm a.; ,; �
r>HONr. "I 6�� . S�7 r- cH �';3
CONTRACTOR NAM� �{ ,� �_, (� .<_���'�, z t 1- C i: � n_ (
SUBMIT A COPY OF
YOUR STATE STATG LICFNSE # EXP DA"I'E
LiCLNSE. BOND AND sT��rE soND a ExP D�TE
CERTT.I'ICATE OF qDDRESS /� �%�-' ''�'t� ii--t�.. `� 1J.� CITY �= rz..i O/tx S1'ATE (": � ZIP �, s�
INSURANCE � �
PHONE '� L;} ?�C \� c�-� I t �i FAX �.J
PERMIT TYPE
TYPE OF WORK:
�SINGL� FAMILY
❑ NEW
❑ TWO FAM[LY ❑ TOWNHOUSE
�PLACEMENT
DETAILED DESCRIPTION OF WORK .�. r�" �ts J 1 � • � � � ' ` ` a x `'1 J n � Q,_`r <� t� � �-� ^s--
FG�S ARE BASED ON $] 0 00 PER FIXTURE: EXCEPT WHERE NOTED. �IXTURES: (WDICAT6 TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$3550.
SATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY L1C) SWIMMING POOL WATER SOFTNER ($35)
CLOTHLS WASHER KITCHEN SINR WATER CLOSCT BACKFLOW PREV. ($15)
DISHWASHER LAUNDRY TRAY 1 WATER I�IEATER ($35) FOR IRRIGATION
WATER M�TER OTHER
Number of'fixhtres C. $1�D.�0 � ���� x $k.0.00 = $
Number�of fixtures� �; $1 S:QO -��_ x $ I 5�.00 — � � � �
Number �f fixtures �d!'535.00 : .� �>>.00 � � „ ��� '= �^'
State Surci�arge � � $ �� 5.00� �
(MINIMIIM $40.00} Totaf $ ° . ' • � '
THIS 1S AN APPLICATION FORA PERMIT-NOT VALID UNTILPROCESSED
I hereby apply for a plumbinb permit and I acknowledge that the information above is complete and accurate; that the work wi11 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�d work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the�ase of all work whi requires review and approv�l of plans.
c� s,�i �. I RINT NAME � �� t� k R. DATE {-�'- f•� -'
SIGNATURF OF APPLICANT i+ �--•. � ' ��`=• E F.�--
APPROVAL INSPECTORS SIGNATURE i� /'�; �, DATL /�� 7 a.-12
V City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 5�43?
763-� 72-3604
FAX: 763-�02-4977