P - 39989From: 763 425 7461 Page: 2/2 Date: 9l15/2011 8:51:23 AM
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Buildin� �',�,�U�B��{y�- Permit No.:Z �w
Inspections R,ESI�]�1�T7�'�.A,I, App��C�i�[`I�N Received By�.�
763-572-3504 CI�'Y C�F �'+`I�ID�EY t�at���:�
763-502-�977 FA.X Er:i:EC�rtvr: �-�-�o� �
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Pl�i2MIT TY3'�
TYPE OF WURK:
YOUR. G-M.AIL AI�I3RESS
11
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sr,�rc uc�rasr �_._(QC1�Q�.._i�`� -- . ""''�xr ���rc �3�,� � i �
S7'ATF BOND � PJ{P L7A'T'k: �,
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t'NONI? 7C� ,;�'-..�L�-:-n—_t`_,°."� -- PAX,���S'_' E'1`,a� �7 "� f-�—�
�SINGLF PAMILY
❑ NFW
DETAILED DESCRlP'I'ION OF WURK
L7'T'WO I'/�MII.,Y ❑ "I'UWN}IVUSF.,
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FEC:S ARi: F3ASBD C�PI �10:(?(i i�t;R FiX711RF', EXCEPT WIiT:RB N01'[:1�. I�IXTURI�S: (lN�ICA'I'k TOT'AL NUM[3�R Ot' L:AC'H II£LOW). MiN1MUM FGE
�:35.Sp.
BATI( SIN�C/I.AV FL.()C)R I�ItAtNS S1-IOW[iR WATC:�t P21'[Nti
_[iAT11TUii C.'rAS PIPING (NEG[) CiTY LtC) SWtIvtMFNG i�OC. WA1'ER 50FTNI3ft ($= 5)
CLOTFIfiS WAS}t3:R KITCHi'N 5INK � WATI:R CLnSf•:T BACKJ'LOW AFi�;V. ($i5)
_ Df4tiWAS}�£it _ LAI3NDRY TRAY N�A'PI:R ItL-ATGR (�35) FOR [R[2IGA?[(3N
_ WATF;iz MF.,7"CR O'T'(�1rR
Number of fxtares @$ i O.OQ
Numb�r of fixtures @ $15.OQ
Number of fi7rtures (a3 $3S.dU
State Surcharge
x $10,00 = $_,�_
x$15.00=�
x $35.00 = $
� S.t30
= � '"T�1 e�
Tt�!!S I5 AN AAPLPCATIC�N FOR A PF:RM1'I'-NUT VAL([7 UNTIL !'FtOCESS£U
i hereby apply for a plumbir�� petmit and [ acknowied�e that the information alsove is corr�plete and accurat�; that the work wilt be in
canforrr�ance with tfie ortlinances and cades ofthe City of'�'rid3ey anti �vith the Miru�esata Construction Codes; that i understand tlais is
not a permit but only an appJication for a p�rnit and work is n to r� without a��rmit on site; tha! the work witl be in accordance
r
with the apprc�ved p�an in the c�Q f ai1 wark � r rr�5ce� ie approv 1 of ta i
SiGNATUiLE(1P' APPLfCArifT �M t! t t'�s ._.. �� tJ u�f..,. 1 unr �j.,�r. r� �r �� ���.�. �^s.,r .�....� c'.,t l���rd
Cl� O�F' I'I(���3'
Suilding �nspectians l�epartment
6431 University Avenue NE, Fridley, MN SS432
763-572-3604
FAX: 7f�3-S02-4977