P - 44460Building PLITMBING Permit No. .`� I(; �` �
Inspections C011/IMERCIAL APPLICATION Received By: ��; `� `�
i63-572-3604 CITY OF FRIDLEY Da�'��� 2��
763-502-4977 FAX
EFFECTIVE 1-1-09
DATE J rj 7�C� � YOUR E-MAIL ADDRE5S /eP ��� i�vltt�L� .; � , c� .v,+-�
SITE ADDRESS ��%�3 1v ,�� � J r
TENANT I��s C�✓LY c� � SUITE NO.
PROPERTY NAME: v/ll��.✓ /�,� i�5 .
OwNER/ ADDRESS: �lo� �Ii �� sS%ooJ Si . CiTY� STATE ��ZIP.5�5"y3�
TENANT rxo�: 7G3 ��75�-D�%y
CONTRACTOR NqME: J wr�v L', �+, /Y/s ic.�/
SUBNIIT A COPY OF STATE L[CENSE # 59,��6 �ia-� EXP DATE /0'2. /O
YOLIR STATE
LICENSE, BOND AND PLUMBING BOND # `� �IC���y_��% EXP DATE /o�lO
CERTIFTCATE OF pDDRESS:,(,�'�/ '-/08'�s` L.,v. CITY� �� STATE/j'1 ��ZIP .�S ��9
INSURANCE pHOAiE�o3 -'��'�i^4�6� FAX 71�:3-7a'y-�'�C�4
PERNIIT TYPE 0�STITUTIONAL Jf�'MUI.1'I FAMILY O SWIMMINGPOOL
❑ TOWNHOUSE ❑ COMMERCIAL/INDUSTRIAL ❑ OTHER
�rYrE oF woRK: ❑ rr�w ❑ �rLnc�rr ❑ p,r.-r�+2�orux�tv,oDn.
DETAILED DESCRIl'TTON OF WORK ���G��� grino �Z
FIXTURES: (INDIGATE TOTAL NUMBER QF EACi�
CLOTHES WASHER , FLOQR DRAITiS ( RPZ VALVE _ URINAL
DISHWASHER ! GAS PIPING BACKFLOW PREV. _ WATER HEATER
DRINKING FOUNTAIN � GREASE TRAP _ ROOF DRAINS _ WATER METER
FAUGET : KTPCHEN SINK _ SHOWER _ WATER PIPING
FL.AMMABLE WASTE TANK �, LAUNDRY TRAY _ SLOP SIiVK _ WATER SOFPENER
� LAVATORY _ S WIMMING POOL _ WATER CLOSET
Total Jab $ �� All fces are based on valuation, including the cast of labor and mate.rials.
Valuation
Pernut Fee $�-'� (1.25% of Job Valuation / Minimum fee: S35)
Surcharge $ � Valuation X .0005
Total Due $ 3J..� Make Checks Payable to: City of Fridley
THIS IS AN APPLICAITON FOR A PERMIT-NOT VALID UN7TL PROCESSED
I hereby apply for a plumbing permit and I aclrnowledge that the information above is camplete and accurabe; tl�t the work will 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 pennit but only an application for a permit and work is not to stazt without a permit on site; thax the work will be in accordance
with the approved plan in the case of a11 work which requires review and approval of plans.
NAME OF APPLICANT �E �• DATE J�% ��
SIGNATURE OF APPLICANT
PLEASE NOTE: SEPARATE PERMITS ARE RE UIRED FOR BtJiLDING ELECTRICAL AND MECHANICAL W�RK " <
City of Fridley Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX:763-502-4977