P - 48545Building
�nspections
76 �-� ;�'_'-3604
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Permit No.:
Received By�! ��
�+��e � .� •
UATL OZ' �-�' �°�' YOUR L-MAIL nDDRESS �
SITi ADDRCSS (0�3� f� t�� ���% � ll�L � � _ _
THIS APPLICANT I� ❑ OWN1iP �'ONTRACTOI:
PROPER�'I
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPI'' OF
YOUR STATE
LICENS�. BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
NAME �IEIYf �b�'P'fJil-)
a��rz�;ss� (oy3�l AS�+� e n /� Ui N� ciT�� F� �r>I��sTaTCrtN zIP SJ ��iL
��FioNr� ���_ a�p — ��.J`1
NAMG _�_���/FPy
STATE LICENSE #
EXP DATE
STATE BOND # EXP DATF
a�vrzESS: �� G � (�/ia.i� �-. �/ E crrv F2 r n 1��_ sTnTE 1N1 �1 zir S'S�13�:
PHONE r% �- '�%.� �F � � I 4 �J FAX
�SWGLE FAMILY
/
❑ NEW
❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
DETAILED DESCRIPTION OF WORK �V1�T'Q.I I rZt IPI �L''9�h� i�0.�lr. �.f LO�.���-
FGGS ARE BASED ON $10.00 PER FIX"CURE, EXCEPT WHERE NOTED.
$35.50.
BATH S1NK/LAV FLOOR DRAINS
BATHTUB GAS PIPING (N�ED CITY LIC)
CLOTHES WASHER KITCHEN SINK
DISHWASHER LAUNDRY TRAY
Number �f�fithn-es C� $10.00 _ s �10.00 �
N�imb�r Qf�fixtures �(ai $1�5�.00 � _ x �13.00 — �_ � _ '
Number of fixtures ccr $35.OQ �_ x��5.00 $�:�• `� t�
State Surchar�e � 5.00
(MINIMtTM $40.00) Total — $ <_a �, . ��,�*�
FIXTURES: (W DICATE TOTAL NUMBER OF F.ACH BELOW). MINIMUM FLE
SHOWER
SWIMMING POOL
WATER CLOSET
�WATER HEATER ($35)
WATER MF,TF,R
WATER PIPING
WATGR SOrTNER ($35)
BACKFLOW PREV. ($15)
POR IRRIGATION
OTI IER
THIS IS AN APPLICA"CION FOP� A PERMI"C-NOT VAL[D UNTIL PROC�SSED
] hereby apply for a plumbing permit and 1 acknowledae that the informaiion above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the 'ty of Fridle�� and with the Minnesota Construction Codes; that ] understand this is
not a permit but only an application for a permit and� rk is n y to start without a permit on site; that the work will be in accordance
with the approved plan in the c e of all work which requir re � w and approval of plans.
SIGNATl1RE OF APPLICANT � i N,f1 E d 1� UATE
APPROV�L INSPECTORS SIGNATITRE DAT _ � -.—
PLEASE NOTE: SEPARATE PERMITS ARER ' FOR ILD . G,' LECTRICAL AND MEC'HA ,A Wa
�j� of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley; MN 5�432
763-572-3604
FAX: 763-�02-4977