P - 48318�uilding
�ns�ectians
763-572-3604
763-502-4977 F�
DATE { � oi /
SITE ADDRESS _
THIS APPLICANT IS
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SUBMIT A COPY OF
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LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
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TYP� O�' WORK:
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F.FFECTIVE 7-1-2010
YOUR E-MAII. ADDRESS
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❑ OWNER �CONTRACTOR
ADDRESS: __�� _CITY.
PHO�: 320• ti� � 2 ��- L
Permit No.:
Received By:
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STATE LICENSE # (nl ��I i7 �� J EXP DATE � Z' I Z�
STATE BUND # ch�' U`'`TL
ADDRESS: � 7�0 �� Dlil.1 ._' CITY '�/A GU(� STATE�\}ZIP 55 ( Zz,
PHONE I/��I1 �
�INGLE FAMII.Y
❑ NEW
DETAILED DESCRIPTION OF WORl�
❑ TWO FAMILY
'�REPLACEMENT
FAX
❑ TOWNHOUSE
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FEES ARE BASED ON $10.00 PER FIXTLJRE, EXCEPT WI�RE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). NIINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER _ WATER PIPING
BATHTUB ' GAS PIPING (NEED CITY LIC) SVJIMIv1ING POOL _ WATER SOFTNER ($35)
v CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PP�EV. (i15)
DISHWASHER LAUNDRY TRAY � WATER HEATER ($35) FOR ffLRIGATION
� WATER METER _ OTHER
Number of fititures,@ $10.00 x $10.00 $
Number offixtures (a�, $I5.00 x $1�.00. $
Number of fixtures @ $35.00 � x $35.00 — $��
State Surcharge ' $ �.00 "
(li'I�NI1G'IU1F� $4'0 00) Total $ �� • ��
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII. PROCESSED
I hereby apply %r a plumbin� permit ana�acknowled�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 ermit and w i �o start without a permit on site; that the work will be in accordance
with the approved plan in the case of a i � rov lans.
SIGNATURE OF APPLICANT T NAIvIE �+Nr1 e� G� I�'��-l-Er DATE �'� � Z—
APPROVAL INSPECTORS SIGNATURE
- PLEASE NOTE: SEPARATB PE REQUIRED F BUILDING, ELECTRICAL AND MECH.�NICAL WORK
�&$� 0$� ��'P.C���y
�r��Il�g ���p���Il��s ��p��°t�n��nt
1 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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