P - 843830
�uilding I�L�T�/I1�I��
Inspections ���� � �TTI l�� �I�L���I���'�Q�l�
763-572-3604 ���� �� �����, �
763-502-4977 F1�X FFFFC'T1VF.7-1-2010
DATE I U " � � ' I �
SITE ADDRESS
THIS APPLICANT IS: ❑ OWNER
�i��PE�2T'�' NAME:�,
���� ADDP.ESS:�i
'g'LI�IAI�IT
PHONE: ��
YOUR E-MAIL
L`�ONTRACTOR
Pennit No.
Received By:��
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�i;yi:la C. i—_ ' I
�-���!��ra��'.7w�,ii�l
C'C1WT��.C1r01� SAME'LICENSE� ,"I 11���,00�•�0,,••.....a EXP,DATE 1a -3�- �a-
SUBMIT A COPY OF
YOUR STATE g� DATE
LICENSE, BOND AND STATE BOND � t;�,1 '�C�5 1340
CERTIFICATE OF �DRESS: e�c-yry CITY sTArE z�
INSURANCE � ��
PHONE ___ ...� rr�nn FAX
PE�iT '��t'PE
TI'PE O��' �%d�RK:
L�SINGLE FAI��II.Y
� NEI�J
DETAILED DESCRIPTION OF WORK
❑ TWO FAMII.Y ❑ TOWNHOUSE
�PLACEMENT
FEES ARE BASED ON $] 0.00 PER FIXTURE, E�CEPT WHEP.E NOTED. FIXTUP�E3: (INDICATE TOTAL NUNiBER OF EACH BELO�. MII`TIMUIv1 FEE
$35.50. WATER PIPING
BATH SINK/LAV _FLOOR DRATNS _ SHOWER WATER SOFTNER ($35)
Bp,�g GAS PIPING (NEED CITY LIC) _ SWIIvID�TG POOL —
CLOTHES WASHER HITCHEN SINI: _BACKFLOW PREV. ($1�)
DISHWASHER LAUNDRY TRAY ATER HEATEF ($35) FOR IRRIGATION
— — OTHER
(1��TIiF�LTf� ��0 00) Tofal $ �� ��
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII. PROCESSED
I hereby apply for a plumbin� permit and I acl:nowledje that the information above is complete and accurate; that the work will be in
conformance ���ith 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 applicatio f rmit and work 's not to start ithout a rmit on site; that the work will be in accordance
with the approved plan in the.e o all work �t�hi ir view nd prov plans� �, DATE �` "��"
SIGNATUP.E OF APPLfCANT N¢ d
APPROVAL INSPECTORS SIGNAT
.: `PLEASE NOTE:.'SEPARATE PE
ARE REQ D F R BUILDING, ELECTRIC.4L AND NIECHA C�`' . ORI� '<`
�i� a�� ]F�-nc��e�
��Ilfl�Il�b Tl�n��ecii�rn� �����'t�rne�n�
6431 University Avenue NE, Fridley, NIl�t 55432
763-572-3604
FAX: 763-502-4977
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