P - 48612From: 763 572 8889 Pa�e: 1/1 Date: 311 6/201 2 7:57:53 AM
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Building
Inspections
763-572-3604
763-502-4977 FAX
DA'fE�� "' / lD "
S1TE ADDRES5 �I
THIS APPLiCANC LS�
PROPERTY
OWNER/
TENANT
CONTRACT�R
SUBMIT A COPX OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSL�RAI3CE
PERM[T TYPE
PLUMBING
RESIDENTIAL APPLICATIUN
CITY UF FRIDLEY
YOUR E-MAIL ADDRESS
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❑ OWNER
PHONE:�(�,'�_,�-1 1 - �3 Q �P�
NAR�: 1 8►�YLf {.]lle v� ra r.0 n v �
STATE L[CENSE # PG OC�� ��'{.-1
STATE BONb # �1 � i l.f..
ADDR6SS: 'J�b'ot E MD.I i-, 5�
PHONE � {J}3 ��o� ��jS �
TYPE OF WORK: I� NEW
FAMILY O TWO FAMILY
❑ R6PI.ACEMENT
DETAILED DESCRIPTIDN OF WORK __ �CQ.!1KCnC-e-
t-t.
c�
Permit
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EXP DATE 1 L �� � '^
EXFDATE ��A
.c�. _ ^ STATE�'�_ i�Z���a.�
! FAX J �D � '7 I � � V �-
C7 TOWNHOUSE
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FEES ARE HASED ON $10.00 PER FLXT[JRE, EXCEPT WHERE NOTED. F1X1'URES: (IND[CATE TOTAL AILJMBER OF EACH BELOW). MINIMUM F�
$35.50.
BATIi SINK/LAV __,_FLOOR DRAINS SHOWER WATER PTPING
gATHTtJB GAS PIPING {NEED C]TY LIC} SW12vfMTNG POOL _ WATER SOFfNER (S35)
CLOTHES WASHER KITCHEN SINK WAT£R CLOSET _ BACKFLOW PREV. ($l5}
DISHWASHER LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
WATER METER OTl-IER
THTS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSBD
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the ' of P idley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and orl� s not to start without a permit-�site; that the work will be in accordance
with the approved plan ia th case o 1 work which req z s review and app val of pl � ,�1
SIGNATURHOPAPPLICA7�tT pR1NTNAME �-C �rrnrt-�oy� � DATE-�-�ZP' 1ti�
�/City of Fridley
Suilding Inspections Department
b431 University Avenue NE, Fridley, MN 55432
?63-572-3604
FAX: 763-502-4977