P - 44461Building PLLTMBING Permit No.:�' � ' �'',, , ;" �'
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Inspections COP►�iMERCIAL APPLICATION Received By: ��;� '-� '
763-572-3604 D ���� � � �Q
763-502-4977 FAX CITY OF FRIDLEY ���'
EFFECTIVE 1-1-09
DATE �`,' �J %%L? YOUR E-MAIL ADDRESS �� �4-Ei1,/�� vYIS't^lnr�.c i'l .! L.�r+-�
S1TE ADDRESS _ �'f�� ,/� �� S`�r
TEIVANT � i/.�s l"� 25 cv e`�?'�' SUITE FJO.
PROPERTY NAME: �%�i�c,t �/L,pr.�/ L� t�
OWNER/ ADDRESS: �(00 !1%ccr cS%��i Si . CITY ��/f,cs STATE M1l!ZIP�
TENANT -
rxor�:_?G3 °57Y o�7y
C�t� 1 l�[11.1 QA "NAM�`: �r'N � .� �iC��/��%#NlG+�1
SUBMIT A COPY OF STATE LICENSE # Jtii�i',�/b P,�,� EXP DATE /a. JO
YDUR STATE
LICENSE, BOND AND PLt11�t1vG Borm # `i 9'e�p��,�7 F3cp DA� �o? JO
C IN U�� F ADDRESS _�f5�/ -'%08 �=` �. CTI'Y��� STATE%1�_�/ZIP �S�
PHONE %l�2 -���/^C�� FAX %1�.�- 7d��i-� t�
PERNIIT T'YPE O INS77TUTTONAL JQ'MULTI FAMILY ❑ SWiMMINGPOOL
❑ TOWNHOUSE � COMMERC7ALlINDUSTRIAL Q p1�IER
TYPE OF WORK• Q�w 0��C�NT O ALTERA7'!ON/REMODEL
DETAILED DESCRIl'TION !3F WOitK ��.F_ Skf ���c� ��Z
FtXNRES: (INDICATE TOTAL NUMBEit OF EACH}
_ CLOTHES WASHER FLOOR DRAINS I RPZ VALVE UIiIPIAL
_ DISHWASHER _ GAS PIPING BACKFLOW PREV. WATER HEAT6R
_ DRINKtNG FOLJNTAIN _ GREASE TRAP _ RUOF DRAIIVS WpTER MBTER
_ FAUCEf _ KiTCiiEN SINK _ SHOWER _ WATER PIP,[NG
_ FL.AMMABLE WASTE TANK _ LAUNDRY TRAY _ SLOP SINK r WATER SOFTENER
_ LAVATORY _ S WIMMING POOL WATER CLOSET
Total3oh $ �� °- AIl fees are based on vaivation, inciuding the cost of labor and materials.
Valuation
Permit Fee $�-�-�` (1.25°10 of Job.Vatuation / Minimum fee: $35}
Surchazge $ � Valuation X .00US
Total Due $�..� Make Checks Payable to: City of Frldky
THIS IS AN APPLICATION FOR A PERMIT-NOT V ALID UN7'IL PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; that the w4rk will be in
conformance with the ordinances and codes of the City of Fridley and wi#h the Minnesota Constructioa Codes; that I understand this is
not a permit but only an application for a permit and work is not to start wiihout a permit on site; that the work will be in accordance
with the approved plan in the case of all work which requires review and approval of plans.
NAME OF APPLICANT �E� � 3 f�:�D
DATE_
SIGNA'C(JRE OF APPLICANT
PLEASE NOTE: SEPARATE PERMTfS ARE RE UIltED FOR BUII.DING, ELECTRICAL AND MECHAPdICAL WORK
�ity or r�r�citey �3uilding lnspectiuns llepartment
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-542-4977