P - 42175_. _��_� From: unknown �LgUlv���� �1412011 10:29:49 AM �v'�v f� ��
�PI'Iriit �0.: U
rnspect�ons CO�M�RCI.A►.L ,A�'PL
763�572-3604 �CATIUN ��ceived By: .
763-502-4977 �'AX CXT�Y CiF F' R�DLEY �ate Rec°a.: � i4 �
EFF$C7[VE 1•1-2011.
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1"�NANT
SUBMtT A COPY 4F
YOUR S'iA,TE
WCENSE, BOND AND
C�RTI�ICATE OF
lNSURA,NCE
FERMIT TYPE
�r�'P� o� wor�K:
SUITE N0.
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ADDR$SS:_ '4 � Z � i CU I�C„�}. �, 1 � ��lTY �''ry�p !
PHONE: �-- � ..�a �� a
NAME:_, � C�i Ck,kcti� S C� V� "T i�_ F� L vh�.�.i�.� .. � 1. u__ .�
$TATE L10EhiSE # C� IQ (�J �' �jr' —
PI.UMBiNG BOND k(�. C, �Q �te i
PHOIVFs �91�"�.� $'+(q b
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DETAILEb DESCR1pTION OF WORK
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'�'� EXP DA']'E j� � 3( � Z4� �
`� � EXPDAtEiI�� 31 I �� i�
_ C17Y ��"k'C1 i'� $TATE �t21P �S` � �.+�
Vh' -�` FAX � �� `"L�,'�„7 '� OC! 1
�MULTI-FAMILY
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�REPLACEME3vT
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IISWIMMCNG POp�.
d AL1'ERAT[ON/REMODEL
� �...,-
F�XTU1'i&S: (1NDICATE TO'['AL NUMBHR OF LACH)
� CLOTHFS WASHEIi „ FLOpR DIiA1NS
,,, D1SHwqgHER _ GAS PIP(NG
_ bRihIKMG FOUNTp11V � G�qSE TRqp
` FAUCET � KITCHEN $IWK
i FLqMMAgLE Wp�TE TANK � LqUNDRY TRqY
Total Job
Valuatfon
Permit Fee
Surcharge
Tot�! p►,e
_ 4AVA7fjRY
$ ���
� RP2 VALVE
BaCKFLOW RREV,
^ ROOF bRqtNS
, SHOIVER
.� SLOP SlNK
,_, SWIMMING pppL
,,,_ URtN/�L
^ WATER H�ATER
` WA7'ER M�'�R
� WATER P'IPiNG
,� WA7'�R SOFTENER
` WA7ER CLOSE'!'
Al! fnes are based on valaation, including the cost of tabor an�d materiala
�-- -�iu (1.25% of Job Valuatian / Minimum f+ee: $35)
� —_._ i � �'Valuation X .pOQS or ll�inimum .50
$-�y''� ^, Make Checks payable to: Cfty af �'�idtey
TH(S 15 AN AFPLICATiQ�i FOR A PERMt7-►dp'r VALID t„tI�iTIL PROC�SSED
I he�eby app1Y for a plumbi�g p�it and 1 acknowledge that the information above is earnplete and accurate; that the worlt will be �n
conf°r't'ance witt�► th,e or8inances and cod�, of �,e City pf Fridley and witla the ivx�inr�esota Cprast�ucCian Codes; that I understarid this is
not a pem�it hut pnly an appl�cat;on for a permit and work is not to st�rt without a permi; on site; tIxat the work vvill be in ac���
with tltie approved plan in the case af aIl w+�rk which uir�cs review and s
� �9 pproval vf platts.
SICiNATURE OF qpPL,1CAN7 : �r-�� �j
PRI NAME: l-�'�-a`-h � DATE; - 1( ��-^II �
ApPIiOVAL INRPR['�'Y'na crn��..,......, � . i� .
�,T� PERMI ARE RE iJIREp �OR �U�LDINQ EL�CTRICA�, ANp 11+lECHANIC
C�ty o� ridley Buildiag Tnspeciions Depat�bment
6431 Uruiversity Av�nu� �'E, �ridleY, �VIN 5�432
763-572-3604 F�1X: 7b3-502-497'i