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i i�eceived b�,
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:�aie Rec' C:
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DAT� �' a-' � a"' �� YOUf: G��1nIL :`,DDl2ES`_:
�I'f�ADUR'�SS SL{'J-$ �N'l..h h`-✓
THlS APPLI��;NT IS' ❑ OWNFR �COPJTPA�TOI:
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SU13M1"1' r'� COPY OP
YOUit STATE
LIC�NS�. BOND AND
CERTIPiCATC OF
1NSURANC�
PEItMIT TYPE
TYPE OF WORK:
1JA�L:y)b �: (. 11`�n J'L^�
��DDP.LSS: ��aS �J'r��"'►� P� �+= CITI' T'r�l[1I �_S"fATLi'(t� ZlR�$�3Z-
r��-�oNC. Z63- 5�1� Sto�
NAML::�y
STATG L[C�NSC #
�XP DAT�
STAT� BOND k �XP DATL•
ADDIZ�SS: Se�'Q d�� ��_ �. N� CITY ��-�.� l� STAT� �''� ZIP SS �3 �
PHONE /�'TI C l�. �.�'� � h FAX
L�SINGL� PAMILY
❑ NEW
❑ TWO FAMILY ❑ TOWNHOU3L
-�REPLACEMENT
DETAILED DESCRIPTION OF WORK �vt 5��� IK.L� � 4�n.�•-�-� W A�� ��-r'��
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER.OF EACH BELOW). MINIMUM FEE
$35.�0.
BATH SINK/LAV FLOOR DRAINS SHOWER _ WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL _ WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN S1NK WATER CLOSET _ BACKFLOW PREV. ($] 5)
DISHWASHER LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
— WATER MET�R _ OTHER
.y- J.VV�':
Total = $ � t'� •'b �
TIIIS IS AN APPLICAI�ION POI: A PLRMIT-NO"1' VALiD UNTIL PROCI�SSED
1 hereby a2�pl�� for a plumbin� permit and � acl<nowi d�e that the information above is complete and accurate: that the worlc will be in
contonnance with the ordinances and codes of the .ity of Pridley and with d�e fvlinnesota Consn•uction Codes; that I understand this is
❑ot a permit b��t only an application � r a perir�it td woric is not t�o start wi�lhout a ��en��it on site; that th� tivori< �vill be in accorda�ce
,vitl� the approvecl »lan in the �ase ���f �ill �- rlc v' ch reqLiires revie�v and cipprovll o��plans.
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