P - 48034� 'From: 763 572 8889 Pa�e: 1'/1 Date: 12/6/2011 12:56:11 PM
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BuilditYg FLI�M$ING permit 1vo.: Z
Inspectivns �
RESIDENTIAL 14PPLICATION �teceivecl sy:.
7�3-s�2-3604 CITY flF FRIDLEY n
763-SQ2-4977 FAX _����___ - - --- ��'�:�
- !Or
THIS APFLICANT tS:
PROPERTY
OWNEIt/
TENANT
❑ OWNER
NAME�
ADDRESS:^�
n �n,.�ti.,�,. '--� _ "1 �.
SUBMIT A COPY OF - --- --• � _ ' "
YOCTR STATE STATE LICE�TSE �,
LICENSE, I30ND AND STATE BOND !!
CERTIFICATE pF ADDRE3S: �
1NSURANCE PHONE �I0 3
PERMIT ?YPE
TYPE OF WORK: I ��w
YOUR �.1yAIL ADDRE3S
d�"'��d-L��/.�7�L
`'� EXP �ATE �
� EXPISATE
7 s'"� ct� �. �
Fnx `y'% 3 - -r, `7 ��'
FAMILY ❑ TWO F,�MILY ❑ T�WNHpUSE
DETATLED DESCRiP'I'ION UF WORK
O REPLACEMENT
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FEE� aRE B�tSED ON $ i0,0o PER FIXTURE, EXCEP'C WHERE NOTED. F[X7URES; ([ND[CATE TOTA�. NTJMBF�t QF EACH BEIAWj. MINIMtlM FEE
sss.sa. . _ ..
_ BATH SINK/LAV ,�,FLOOR DRAINS _ SH4WEIt _ WATER P�ING
_$ATHNB GA5 FIPING iNEED C77Y LIC) _ SWIMMiING PdOI. , WATER SflFTN6R ($35)
T CI.,QIHES WASHER _ 1CITCHEN SINK T WATER CIASET � BhCKFLOW PRFsV. ($15)
_ DTSHWASHFR _ LqL1NL7RY TRAY _WqTER H�ATER ($357 �'OA IRRIG?�TION
_ V�IATEFt METIIt QTHER
THIS [S AN APPLICATIOkI FOR A P$RMIT-NOT VALID UNTIL PROCESSEp
I hereby apply for a plumbing permit and I acknowledga that the infomiation above is completc and accurate; that the work will bc in
copfomience with the ordinances and c,odes of thc City of Fridley a.nd with the Minnesota Construction Codes; that I understand this is
not a permit but only an a�plication for a pexcnit and work is nat to start withant a permit on site; #hat tho work wip be in accordance
with the appmved plsm ' e of rk which roquires review and ap of 1 is. f /
sIaNATURE O� APPLIC�+1 � � p p�� �%
PRINT NAME �'�1'� DATE f (f� /
APPROVAL INSPECTQRS'�IGNATU�- i � . ,r : .. �-- � �. ,.' - - -
City of Fridley
Building Inspections Department
b431 UniversitX Avenue NE, Fridley, MN 55432
763-572-3604
FA3�: ?b3=542-4977