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I �L117C�.111�' �'�«.J��� `f���,,.— Permit No.: �L�L�,
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�I2S�eCt1011S � � � ��;�1', '�'�� � �� �'�'� �� � :� Received By: /
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� 763-502-4977 F�X � � EFF�cr1v��-ie-o� � I�
DATE ���,�I� � � YOUR L-MAIL ADDRLSS �
SITL- ADDRLSS J� I' �� �� �Y
TI-IlS APPLICANT l5: ❑ OWNEP. �ONTRACTOR
PROPERii' NAM�: l.Glr(�- ��S
OWNER/ ADDRESS: 7/J 1 7� �%� �� CITY �l���i' STAT - ZIP_
TEI�iAN'T �xorr�: �I Z � '!'"l �j - l�( � g
CONTRACTOR NAME: � V� � � � 'l
SUBMIT A COPY OF STATE LICENSE # EXP DATL
YOUR STATL
LIC�NSE, (30ND AND STATE BOND # EXP DAT�
C�RTIPICAT� OF ADDRESS: D�tt � N�/�vl �, �/V� ��� CITY i � STATE ZIP y S� �'Z
:NSURANCE pHONE °j_� � "` � `t ` � � FAX �}(v 5 ' �S`I � � �`Q�
PERMIT TYPE �TNGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: 0 NEW �2EPLACEMENT
DETAILED DESCRIPTION OF WORK i IDY1I '►ti°
FEES ARE BASED ON $10.00 PER F�CTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVI�. MINIMITM FEE
$35,50.
BATH SINK/LAV _FLOOIt DRAINS SFIOWER _ WATERPIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMNIING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATERCLOSET �BACKFi..OW PREV. ($l5)
DLSHWASHER LAUNDRY TRAY WATEA HEATER ($35) FOR IRRIGATION
— _ WATER METER _ OTHER
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i�iu�bex-e��fixtutes � �35 �0 �� �..�35" QO��� $� �, , ���, � � '� ,� , �' � '� *" � �
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THIS IS AN APPLICATION POR A PEILMIT-NOT VALID UNTZL PROCESSED
I hereby apply for a plumbing pezmit and I acl<nowledge that the information above is complete and accurate; that the work will 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 �pplication for a permit and worlc is not to start without a permit on site; that tlte worlc will be in accordance
wit11 the approved plan in the case of all worlc tivhich requires review and approval of pians.
S1G�A'ZURL OF ��1PPL1C�INT �/,d� �' ��� 1'RINT NAM� ��l l�K ������ DATL ��� � G t3
i'C,���:SE iv(�'T�: SEP.�IR3TT�'PERi�(ITS .lR� R�(�liTR�D �nR 3QILDING; I�LLr'TRTC,?:L AND �![ECH,�i'�liC.4L WORI� !
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�'itr� o� �rtc��ey
���flc�a�a� ��as�e�i3ons �e�a�-�t���a�
64�1 Univarsiry Avenue NC. Fridley. lVIN �54�?
763-�7?-360�
F.�:C: 76�-�0?-�977