P - 48428From: 763 572 8889 Pa�e: ?J2 Date: 2/17/2012 10:09:51 AM
. �... � _ ........ .... . � ....��. ........ . �.....,..�..b ....... .....� ..........
Building
II1S�7�'Ct1011S
763-5?2-3fiU4
763-502-4977 FAX
DATE da " � � "
STI� ADDRSSS �
'PHIS APPLiCANT 19:
O'WI�TER!
TENANT
SUBNi1T A CC)PY OF
YdUR STATE
LiCENSE, BQND AND
CEB'I'IFICAITE OF'
INSURI4NCE
PERMIT TYPE
TYPE QF WORK;:
I'LUMBIN�
1tESIDENTIAL APPLICATIUI�
CITY OF FRIDLEY
❑ OWI�iER
NAINE:_�,�, ,i
ADDR$SS: c..�l. �i
PHONE:,��
x��: �"� �-�r`-t
STATE LICEN�E #_
STA"CE BQND #,,C
ftiDDRES�
PHC#NE' to �i -
`�SIt�GLB FAMILY
❑ NEW
DETAILED UESGRIPTiON C�� 'i�4tORK,
YOiJR E-MAiL ADDRE5S
�d � -- � t�• O �
L7v�act�r f
Q' C Gx� 1�kS"l
>�'? ' �„
� Mui�
�i"'f;� ° �$' �sb
❑ TWO FAM[LY
p REPLACEMENT
��
Perrnit No.:l1U1 UUUI_ 15 �
Received By;�
D����: + 1
EXP BAl'E
EXP DATE
CITY ��1 C � STATE �� -ZIP�• ��
FnX "7Co'.� 57 3- � �' St''S'�,,.,
D TOV/NHOUSE
FEFS AR& BASED ON S IU.W PSR FIXTURE„ BXCEPT WHERE NdTED. FIX71iRF.S: (IND7CA1'E TCYC'AL NUMBER OF EACH 9ELQVt�j. MINIMUM FEE
�50.
BATH SIPiKILAV FLOf?R �RAINS �SHOWER �,WATERPiPiNG
BATHNB Gt�S PFPIAiG (NEED CITY LIC) 5 WIMMING POO[. � Vkt�'�'� gp�'(�IER ($35)
iGLOTHES wASHER KI'FCHEAI SINK � WATER CLOSE'f _HACKFLOW PREV. (S1S)
! pISHWASHER ! LAU!VI?RY TRAY WATER HEATBR ($35 ) EOR IRR]GATTON
'— � _ WATF.rt IvIETETt _ OTHfsR
THI913 APV APPLIGATION FOR A PERMIT-VOT VAL1D UNTIL PROGESSED
1 itaroby apply for a plumbing perrnrt and I acknowledge that the inforn�ation abave is complete and accurate; thai the work wil! be in
conformance witk tho ordinances and codes of the City of Fridley and with the Mitunesota Conslruction Codes; ti�at I understand this is
not a pennit bt�t only en apptica.tian for a permit and woii: is not to start withaut a permit on site; ihat tha wark will be in accordanee
wiii� the approved Plaa in the e af al work which reauirBS review and app val of pl�Sr ,
31GNATURL' OF APPI.ICAN'1' [��,�. PRI�t't NAh�� �✓� f' �T`L'S;rrim G✓1S AATE �`�?���
City of Fridley
Building Inspectians Department
6431 University Avenue NE, Fr�dlcy, MN 55432
'7fi3•572-3604
FAX: 763-SQ2-4977