P - 42257�uilding �� �T1�����
�nspections ���`��l'°����a�� ������1�1� ���1"'�
%6.3-J%�-�6��
763-502-4977 FA.; ���� �� ����� ��
EFFECTIVL ^-19-09
DATE �V�(WD'(�
SiTL• ADDRL-SS
TIIIS APPLICANT ]S:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A CQPY OF
YOUR STATE
LIC�NSE, BOND AND
C�RTIFICATE OF
INSURANCE
PERMIT TYPE
�rYrE oF woxx:
I�� � fl�c XaC
❑ OWNEP� �
NAMG: G � N`
ADDRESS:_ , � (O�I
PHONC: � �S
NAME:
STATE LICENSE#
STATE BOND #
PHONE � fi11 � — �'-I'
�l SINGLE FAMILY
❑ NEW
DETAII,ED DESCRIl'TION OF WORK
YOUR L-MAIL ADDR�55
❑ TWO FAMILY
f�EPLACEMENT
CITY�
FAX
❑ TOWNHOUSE
Permit No.
Received By:
EXP DATE
EXP DATL
S
FEES P.RE BASID ON $1�.00 PER FIXTURE, EXCEPT WI�RE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV�. MINIMUIv1 FEE
$35,50.
BATH SINK/LAV _FLOOR DRAINS SHOWER _ WATERPIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWINAZIIa1G POOL WATER SOFTNER ($3�
CLOTHES WASHER KITCHEN SINK WATERCLOSET BACKFLOW PREV. ($l�
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR Ii2RIGATiON
_WATERMETER _ QTF�R
THIS IS AN APPLICATION POR A PERMIT-NOT VALID CTNTIL PROCESSLD
I hereby apply for a plumbin' permit and I acicnowled�e that the information above is complete and accurate; 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 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 worlc will be in accordance
with the approved plan in the c of al( work which requires review and approval of plans.
SIGNATUP.�OPAPPLiCANT ��Gr/li/`'� �'•'�" V'T�v PRINTNFlME ,,�N�- ���- - -- �ATL�lfv��(�
Pt;�A:SE N�T.E.: 5EP
�il� O� �'T1C��e�'
��a��+dgng Iuas�e�i3ons i�e���-t�ne�t
b431 University Avenue NC. Pridley, N[N »43?
763-�7?-�60�
FAX: 763-�Q2-�977
WORI�