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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:�� � A �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 �