P - 42234Building PLUNIBING P�lt No=:
Inspections RESiDENTIAL APPLI�ATION R ' ��
7b3-s72-3604 ��TY OF FRIDL Y D$��''d�
7$3-SQ2'Q'977 F�A.X EFFSC71VE2-14-09
DATE �%RJ � 0 . YOUR E-MA1L AUDRESS
SiTE ADL)RESS �+ ! 3 (o�' - ; �-C!� A.l �
THIS APPWCANT' 1S: � OWNER �ONTRAC'COR
PHOPERTY rtAME: � � � � o
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TENANT PHONe: "? 3 - S�� - 'S �. � � _.
SUHMIT A CAP'Y OF
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LICEN5E, BONb AND
CERTFFiCA'1'E Oi
INSURANCfi
PERMTT TYY�
�r�tPE oF wo�uc:
NAME:
STATS LiCENSE M_
S'f'ATE SOND 11 �,,,�
ADDRESS:
PHONE
Terry Overacker PlumbinS.
502 E Main Straet
Anoka, MN 55303
L'�censelt 061945PM
763-592-8880
�SfNGLE FAMILY ❑ TWO EAMILY C]
❑ NBw �REPLACEMENT
DE'fAILED DESGRIP'T14N OF WORK
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_ EXP DAFE
_ EXP DATE
S7ATE L'IP
FEES ARE HASED ON SI0.00 PER FIXTUItE, EXCEPT WH£RE NO'CED. FIXTURES: UNDIC TE TOTAL NLFMBER OF EACi18E40W}. MINIMUM FEE
535.50.
BATFI SIN1C/LAV FLOOR DRAINS SHOWER VIJATER PIPWG
BATHTUB GAS P[PFNG (N�ED CITY L1C) SWlMM G POOL _ WATER SOFTNER (S35)
CLO'THiS WASHER 1C[TCHEN StNK WA'i'6R LOSEi' BACKFLOW PREV. (S15}
� DISHWASiiER � LAU!VBRY TRAY WATER HEA1'ER (533) � FOR IRRIQA'fldN
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TBI3 [S AN APP4tCAT10N FOR A PERMIT-NOT VALiD UNTIL PROCESSED
I hereby appty for a plumbing permit and I acknowledge ckiat the infosmation above is complece and accurate; that the work wilt be in
comfocsuance wich the �rdinances and codes of the City of Fridley sad with the Minnesota Construction Codes; that I understand this is
riOt a petmit but anly azt appiication for a permit and work is not to start without a partnit on site; lhat ihe work will be in accordance
with the approved plan in the case of all work which requires review and approva] of plans.
SIGNAl'URE4F APPLICANT �� �►"'�' PRINT NAME `/� C K �� �'k''� •�� pq'i'E �l ���Z c)
City of Fridley
Building Inspections Department
643I Universiry Avenue AtE, F�idley, MN 55432
763• 5'72-3604
FAX: 763-SU2-4977
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