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Inspections COMl�/IERCIAL APPLICATION Recei�ea sy: .' ��� `'�
763-572-3604
763-502-4977 FAX �ITY OF FR,IDLEY D���'I� �
EFFECTIVE 1-i-09
DATE � %% %� YOURE-MAILADDRESS IC'N � �i�ly �:•�•� :✓JS•� � .i'r�> .-,.,».,,.,,�
SITE ABDRESS _ `p�� �.�, ,�� S�r �
TENANT ��f/ r� 2s c.v � a� SU[TE NO.
PROPERTY NAME: !/!ll/��ii" �lL�: r.✓ � �
��E� ADDRESS: �{(,aCa !i%j rt� cc��,f Si CITY �...,,�d%�, STATE �%�ZIP�
TENANT PHONE:_ '�i'bS'�%/ ��,�%rf
CONTRACTOR NAME: �t'�v (��y�z, 1`�fic,���a�vrc.¢%
SUBMIT A COPY OF -��
YOUR STATE STATE LICENSE # S9',�I�* P/�+ EXP DATE ___/oZ /47
LIGENSE, BOND ANI7 PLUMBING BOND #! `7_ `�'C�p��'�"7 EXP DATE __ fe�lC?
CERTIFICATE OF ���SS: �e�/ .- fa� ia. � C�'y ��,L, r STATEl1'i_�ZIP1�S�
iNSURANCE PHONE _�7,f�� °��LI ^O�� FAX 7G�- 7d�C/-t9�C7 "�
PERMTT TYPE O INSTITlJTIONAL JQ'MULTI-FAM(LY ❑ SWIMMINGP�L
❑ TOWNHOUSE ❑ CONIMERCIAL/INDUSTRIAL ❑ OTt�R
TYPE OF WORK• ❑��' ❑ REPLACEMENT ❑ ALTERATION/REMODII.
DETAII.ED DESCRIl'TTON OF WORK ��� F�� ��j�� ��
FIXTURES: (INpICATE TOTAL NUMBER OF EACi�
_ CLOTHES WASHER _ FLOOR DRAINS 1 RpZ VALVE � LJRIT(A[„
_DISHWASHER _GAS FIPWG BACKFLOW PREV. WATER HEA7'pt
_ DRIIYKING FOUNTAIN ! GREASE TRAP _ ROOF DRAINS WATER METER
_ FAUCEf _ KITCHEN SINK _ SHOWER WATIIt PIPING
FLAMMABLE WASTE TANK _ LAUNDRY TRAY _ SLOP SINK WATER SOFfENER
_ LAVATORY _ SW[MMING POOL _ WATER CL05ET
Total Job $ C� ""'— A11 fees are based on valuation, including the cost of labor and materials.
Valuation
Permit Fee $ "� S" �(1.25% of Job Valua#ion / Minimum fee: �35)
S�b� $ � Valuation X .0005
Total Due $�7,,�f1 Make Checks Payable to: �ty of Fridley
THIS IS AN APPLICATION FOR A PERMiT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I aclmowledge that the information above is comple�e and accurate; that the work will be in
conformance with the ordinances and codes of the City af Fridiey and with the Minnesota Constructian Cades; 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 accorclance
with the approved plan in the case of all wo�ic which requires review and approval of plans.
NAME OF APPLICANT �EL. �• DATE J%%%C%
SIGNAT(IRE OF APPLICANT
PLEASE NOTE: SEPARATE PERMITS ARE RE UIltED FOR BtTII.DING, ELECTRICAL AND MECHANICAL WORK
�:ity oi r�ridley �suuuzng lnspections liepartment
6431 University Avenue NE, Fridley, MN 55432
763-572-36Q4 FAX:763-502-4977