P - 42769�`
Building PLUMBING Permit No.:
Inspections COMMERCIAL APPLICATION Received By: �'
763-572-3604 Date Rec'd: �r'
763-502-4977 FAX CITY OF FRIDLEY ��,� �� a 2��
EFFECTIVE 1-1-2011.
DATE �-Z 1 �OUR E-MAIL ADDRESS , r 1�'2�y �CnK � A� � f'�O`�!'4� � e�D �
SITEADDRESS �I %`f � U E' �, �
TENANT SUITE NO.
PROPERTY NAME: ' Fk�t-��wS
OWNER/ ADD�ss:, / �/ /� — 5 r�'
TENANT � � ��� ��TY ��� STATE �N Z[P S�?O�
PHONE: �� i �l %-7 �% � S-Sr
CONTRACTOR NAME: G � ��' � 5 �/
SUBMIT A COPY OF STATE LICENSE # C� S` � y S �f✓�
YOUR STATE �i ` EXP DATE /� 3 ��I�—
LICENSE, BOND AND PLUMBING BOND t! EXP DATE
CERTIFICATE OF ADDRESS: t/8 3 �l�Y ?� CITY �/ur�"� °`1 S` �� STATE�ZIP 5"� 35"�
INSURANCE pHONE Cr i..Z � U 3 /�`s / G; FAX
PERMIT TYPE � INSTITUTIONAL ❑ MULTI-FAMILY ❑ SWIMMING POOL
❑ TOWNHOUSE "B-SQMMERCIAUINDUSTRIAL ❑ OTHER
TYPE OF WORK: � NEW ❑ REPLACEMENT �E}�41tTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �� �I�C' e {�'I/� i,n 5'�� � c�.� G.J�►¢,� ��j,yt j„�.�
� ° � �P 4 . c�� (, �.,, �'i•�-
,
xI�TY3Tt�5: (Il�ii�ICA"Y:E TO'I`Ai,. N(JM$�R d� EACH}
_ CLOTHES WASHER _ FLOOR DRAINS _ RPZ VALVE URINAL
_ DISHWASHER _ GAS PIPTNG BACKFLOW PREV. ' WATER HEATER
_ DRINKING FOUNTAIN _ GREASE TRAP _ ROOF DRAINS WATER METER
_ FAUCET _ KITCHEN SINK _ SHOWER 4 WATER PIPING
_ FLAMMA$LE WASTE TANK _ LAUNDRY TRAY _ SL4P SINK WATER SOFTENER
_ LAVATORY _ SWIMMING POOL ` WATER CLOSET
� ��;�s � � � � � '� � ,� �
>.: ,.
.�,.a.���;,�. ., ��t?� � „_.. � *r�'� ��,�, � , � �� r ' �, ��.,�: > �a�.��, ��._, .�,'� �_,�,; , ,� : :: . :��r„��� _ ��,�. .,, �; ."a�`� _.,.�_ . .��.4�..����e
Total Job $ S�l�_ ^All fees are based on valuation, including the cost of labor and materials.
Valuation
Permit Fee $� (1.25% of Job Valuation / Minimum fee: $35)
Surcharge $___�_ Valuation X.0005 or Minimum .50
Total Due $_s� Make Checks Payable to; City of Fridley
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; that the work wip 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 a permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case of all work which re uires review and approval of plans.
SIGNATURE OF APPLICANT : PRINT NAME: �� 1 � Q r�"" DATE: 3 ( �
APPROVAL INSPECTOR SIGNATURE: ..... �V DATE:
;'I?!I.������'JJ�'��' �s�'�T� �'�� � �. U�� F'�� BUII.:�II+TG,",�L�"CTF���z�I;. �� ME�-I�1�1���, ;'� _ �� ;.
City of Frid Buitding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977