P - 44463$uilding PLUIYIBING permitrto.: �� i� ��= � �-►
Inspections �(}��ERCIAL APPLICATI(JN R��� ed • t'�� '
763-572-3604 Date ��c'� ` � '
763-502-4977 FAX CIT� OF FRIDLEY
EFFECTIVE 1-i-04
BATE �S �� 7 �d YOUR E-MAIL ADDRESS _=y� ��} � � � ;� `.�f y/s�-L,�.�. `c � c �f,..�
SiTE ADDRESS _ �j�j�'�7 � �� �";", '
TENANT (0_ f(//.?r r C� 2� cti ,�� SUITE NO.
PROPERTY �pMg: �'/j�s �2�'r.�/ /�a {�' .
� ��,� ADDRESS: '�{(p4lYf�ccresi�r�l Si CITY �d%�c, STATE�I�ZIP�
PHONE:_763°Jr%5� D�+%f
CONTRACTOR rrn�: i��a�v Le ¢z, /�%s �7 ic+�%
SUBMIT A COPY OF "-7
1TOUR STATE STATE LICENSE # S9',.,?/6 P� EXP DATE /0'2 JQ
LICENSE, BOND AND PLUAqBI1VG BOND # %9'Cjp�t '.f�r'�'7 EXP DATE /o�lO
C 1NSURANCE � ADDRESS: � I'-JOS �` LA.� CITY�.� ,�G STATE�ZIP��iI�
PHONE `7!'o,^S -7iS'��''!^G i� FAX 7�a�- 7ccS'�-P��'�
PERNIlT TYPE Q�S���O��' �MULTI-FANIILY O SWIMMING POOL
O TOWNHOUSE 0 COMMERCIAWINDUSTRIAL ❑ p7T�TER
TYrE oF woRK: ° �`' ❑ �'�c�',- o �.'�nnorux�ar,on�.
DETAILED DESCRII'TION OF WORK �f/�Jn.G.� S�1 ���,a 12�Z
.
FIXNRES: (INDICATE TOTAL NUMBER OF EACH)
_ CLOTHES WASHER _ FLOOR DRAINS � RPZ VALVE IJI2Iidqy
_DISHWASHER _GAS PIPING BACKFLOW PREV. WATERHEATER
_ DRINKING FOUNTAIN , GREASE TRAP _ ROOF DRAINS WA'IER METER
_ FAUCET _ KiTCHEN SIIJIC _ SHOWER _ WATER PIPING
_ FLAMMABLE WASTE TANK _ LAUNDRY TRAY _ SLflP SRVK WATER SOFfIIVER
_ LAVATQRY _ SW[MMliVG POOL WATER CLOSET
Totat Job S �'- All fces are base.d on valuation, including the cost of labor and materiais.
Vaiva6on
Permit Fee $�j�-'' (1.25% of Job Valuation / Minimum fee: $35)
Surcharge $ r.�0 Valuation X .(}005
Totat Due $�%� Make Checks Payable to, City of Fridtey
THIS IS AIN APPi.ICA'fiOAT FOR A PERM[T NOT VALID UAl7iL PROCESSED
I hereby apply far a pl�unbing permit and I acknowledge that the infonnation above is complete and accuraxe; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I anderstand this is
not a permit but only an apglication for a permit and work is not to start without a permii on site; that the work will be in accordance
with the approved plan in the case of ail work which requires review and approval of plans.
NAME OF APPLICANT �E b�/. DATE �%� /O
SIGNATURE OF APPLICANT -
PLEASE NOTE: SEPARATE PERMTfS ARE RE UIItED FOR BUILDING, ELECI1tICAL AND MECHANICAL WORK
c:ity ot r�rinley �3uilding lnspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977