P - 40105From: 763 572 8889 Page: 2/2 Date: 9/16/2011 10:28:34 AM
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BLit�(�lll�,
Inspections
763-572-3604
7b3-502-4977 FAX
L]ATE `�, ` � '
SITE A1DDR�SS �
THIS APPLICAIVT [S:
01�VNER}
TENANT
PLUMBI�G
RESIDENTIAL APPLICAT�ON
CITY t�F FRIDL.EY
E-MfAll AS3DiLESS
R OWNER OCON7RACTOR
CtTY
Permit Na.:
Date
— ' ` —,-
SUHMiT A COP'Y OF STATE LlCENS6 # �(�G�' ��'S I��J �••J EXP DATE ����I Z
YOUlt STATE �
LICENSE, BO1�iD AND STATE BOND #t ON �J L-�� E7i:P DATE
CERTIFICA'T'E OF ADDRBSS:� F��n) S� C1TY�,�,'�- STATE��ZfP�
R�i$URANCH PHONE 1���.3 �$S�r FAX "j (p�` S'?� � iSflS�9
PERMIT ^fYPE
�rY�� a� woRx:
SR*IGLE FAMILY
O NEW
DETAILED DESCRIPTION OF WORK
❑TwO FAM[LY ❑ TOwNHOUSE
,I�R�PLACEMENT
FE+£S ARE SASED ON $10.00 PER FIXTURE, FJCGEPT' WHERE i+IflFED. FI7i7URES: ([NDICATE TOTAL YUMB�R OF 6ACH BELOWj. Mt1�t1MUM FEE
533.50_ .
BAT'HSIT�IK/LAV �FLOORiyRAfMS SHOWER WA7'ERPIP[NG
gprl{�8 GAS PIQCI�IG (NEEa CTTY L{G) r SWIMMING POiDI. _ WATER SOFI'NER f�35�
CLOTHES WASHER ! K1TC1#EN SINtf � WATER CtOSET _ BACKFLQW PREY_ (SIS}
DISHWASHEEt LAUNDRY 7RAY WA'fER HEATER (SIS) FOR [RRICATION
� — �[ WATBR METER � dT'HER
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TH[S IS AN APPLlCA7iON FOR A PERMIT-NOT VALlD UNT1L PR�CESSED
I hereby apply far a pl�mbing persnit and I acknowledge that the information abave is complete and sccurate; ti]at t�1e wqCk wjll be ia
confarniance with the ordinances and codag of the C� of Fridiey and with the M'snnesota Cnnsavction Codes; that I undersrand this is
aat a pemut but only an applicatiorrfor a acmic d ark is not to scart withouc a pecmic on site; that the work wiil be in accardance
with the approved pian in the e iv ch quire review and appmvai of p s. DA"CE ��
SSGNATURE OF APPLI�ANT j 1NT NAME'�
!�,� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572•3604
FAX: 7b3-502-4977
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