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P - 48622From: 61 2 827 8129 Page: 212 Date: 3/20/2Ufi2 '42:21:26 PM ,,,.,,. "„ ��.. �,.. �..,,, ,.�,� �,,, , .,.,,.�, ,, ,.�, � �,,,, �'Ull(�311�, ��..��V' Ferintlit Na I�spe�txons I�E'►�II�ENTIAL APPLI�ATIUN Re�ezved 1 753-572�3644� ��'�"� (3�` �'+ �DLEY Dace 1�( 7�i3-502-4977 F.AX ,�r-t.�„�,_,_��,� SITE AI]DR£�.SS � 'I'FIIS APPLICANT IS: OW1V��t/ TENANT St7�MI"r A COPY 0� 'YOUR STATFs z,zcErrs�, �soriz� �r CERTIk'ZGATE QF YNS1'JRA,N'C� l��T T''Y�� '�� O�''t�VbAt�{: s f � �. sr�r� �eoxn7 # r AIJDRFkSS:,.�` �'+ rr� PHONE � �P �� 'SINCrLE F.A�MI�S,Y o rr�w YOUR E-MAII, A,L1D1i�5S �orrr�ncro� l: `�';1rJ � iYE. '� E77� AA'�'Fs ,,�,�� EXP DATE �� .�+Wd 1..��f�CITx +-�-D �'3 F.nx Ctv t i'•] S � Ti�O F�II.X =I TOWNti�US� J��rLAC�M�' . b�TATi,�17 T�L��C�T1fON OF WOZtK Yf..l7lGLGG- CY� P.•�17'..�Ir �/'Ll � V� S . ,, �S A1tE BAS� dN 510.00 PER FIXTURE, EXC.EP'P WHf.RE NOTED. FI3(1VRES: (INUICAT'E TOTAL N[]MS£R dF EACH BELOV�. MWIlKUM � $35'30. BATH SIIJK/GSV ��YAOi2 D�tAYNS SH'OWER w'CN',4iER F�"R`TCr � BATH'IZ7H GAS FIE'II�TG (NE�D GT!'Y LIC} � Se�+�II�iG pf)QL wATBR S4F��t (5�35� _ GLOI'f�S WAS�ER _ K1TCiIEN SINK _ WATER CLQSET � BAC�T.OW PR�T. (SI � �„ I7ISHWASFIC�R Lt#UNAxLY TRAiC W:A;CE�R i�6AA'�'ER (S35) FOR IRRIC�ATION � WATER MIsTIIt fOTFTETt Nu�ber af fuctures Qa �IOAO �' 4ae,$L�O:ao =� ,..�I�...�,,�, .. Numb�►r of fi�ct�ures � $�5 d0 ��.'�`t1r�,.$15'.40 = $��. ' i } � � ; Num6eR of �'ixtures Qa $35.00 l x $35.,0;0 = $. � • �' ..State Surcharge .,� . - . . $ S.bO :,:.s� , : �,p rnmvn►�tnvr�aa.00�..: °` ...:�otat=� �'t1. � �:. , «� a1.:�,' . , :, � � •' � .. . .,.;{ .., , , , ��e��= .. TFIIS IS AN APPL�IGATION FdR A PERMTT•NOT VAI.1D LiN1IL PR(aGES58D I heraby apply for a plumbing perm�t and I ac�owled�e tk�at t)ae iz�orrnatioA above is c�omp�ete aad accurate; that the wozlc will be in confo�ce with the osdinances and codes of the Ciry of �sidley and wfth the Muaaesota Gonsttuctio�a Codesr t�at Y understand t�i:s is IIOt a peT�lit but aIIly aII app�lcation �or it and work is �c,t to sr,art without a pw�mi� Qn sitey that the w'ork WiII be iA B�GCDrdsnCo with #b:� appraved plan in the e af a�l ��'r�#�,�y� re4uires review and approvsl of lau�s. ��r�nzv� aF �.m�rrr.�r�+�".Y-` � 1 l„ n. ��rr xar� Je�+°�1 L� tV�� c'r+�`�'paz� �1201 ��1. _ �City a� Fr�diey �uilding ��spect�oau� pe�artuient 6431 CSnivexsxty A,vez�ue lV�, �ridley, MN 55432 763-572-3604 FAX: 7b3�502-4977 �