P - 42192Building
Inspections
763-572-3604
763-502-4977 FAX
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TFUS APPL[CANT IS:
PROPERTY
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From: 763 754 0066 Page: 2/2 Date: 4/18/2011 3:09:57 PM
PLU�VIBING Fe�� ivo.:2
RESIDENTIAL APPLICATIO�T Received By:,
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CITY QF FRIDLEY Da�'
FFF£f`TNF 1-1-201] ._
YOEIft �MAIL :4DQRESS , Y � �� U ��1�'"_� �.�.- � U f�'IL�� ! T� 1� • LC � -
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= 57�'��S�D
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SUBMIT A COPY OF gTA78 LICENSE # (�C ��.��— M FX4' DATE _ I�`� �: ` �
YOUR STATE EXp DA7'� � a- 3l -� �
LICIIVSE, SOND nND ST.4TB BOND � W O �,, �
CERTIFICATE OF ,��p,�s: � �5g 1 a3"— 1'1v� �'� CITY �'^ �`�'� �f STATEI`MI (� ZEP SrJ���
nvsuRaNCE p�orr� _ lo���- o�' �� Fnx -7 to3 -7 s�i--c�u �o i..P
PERMIT TXPE
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FAMILY L17tiVOFAMILY ❑ TOWNHO[ISE
I�REPLACEMENT
DETAII.,ED DESCRIP"fiON �F W�RK ...L1'1 S�"A 4! .—"
FfiES ARE BASED ON SI0.00 PER FDCTURE, S7CCEPT WFIE�RE NOTED. FIX'y'LTRES: (INDICA7'E TO'i'AL T[UivlSER. OF EACH BELQW j. b�lIMti M FFE
E35.i0. WATER PIPING
BA'CH SINK![.AV _FLOOR DRAIN3 _ SHOWER
� BA7HT[JB GAS PIPING (�`1FiED CITY LiC} _ SWQ'�VII1vG POOL � li'AT£R SOFTNER {S35)
CLOTHES wASE�R _KTi'CHEN SINK waTERCLOSET _BACgFLOW PREV. (E!�
I}ISHWASIiER _ LAUNARY T7tAY ,,,_W'ATER EI@ATER (S3s� FOR IRRIGAT[ON
-- WATER METER _QT��
Number of fixtures (a3 $10.0o x�] tF,00 = S
l�umber of fixtures ��15.� x S1S.00 =$
Numbor af fi�dures (a; $35.00 � x $35•4� _ �� �
S`t�te 5urcharge
$ 5•Q3!
= S "1.�.1 . � �
THIS IS AN APPLICATlOI3 FOR A PERMI'I-NOT VAI.ID UN7IL PROC£9S�D
I i►ereby appty for a plumbing pernrit and I adcnowledge tlmt the information above is complete and acc�n'ate, that the woxk will6e in
conformance with the ordinances and of the City of Fsidley and with the Minnesota Conslruction Codes; that I unclerstand this is
nat a pennit but only an applecation for a it wark is nat to start without a permit on site; that the work will be in aoca'da�nce
with the approved plan in the c e of al! wo w z+equires revieu' and ePP�'Q�� ��� P1�� {,� _(�i'�7T�
SiCsAEATUREOF APPLICANT P�TN�--�- � � t� �e-rn-`� �� G
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" City of Fridley
Baildin.g �nspections Department
6431 University Avez�ue NE, Fridley, MN 55432
?63-572-3604
FAX: 763-502-4977
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