P - 35478Building PLUMBING PermitNo.: �4fva�
Inspections COMMERCIAL APPLICATION Received B�:
763-572-3604 �
763-502-4977 FAX CITY OF FRIDLEY Date r��t.
EFFECTIVE ]-]-2010
DATE � �1 '��' I V / YOUR E-MAIL ADDRESS
SITE ADDRESS �/�� I l�1 ��t, n n� �ZD
TENANT SUITE NO.
PROPERTY NAME: S .e /-� t
OWNER/ ADDRESS: % J C /Le-% � CITY STATE�i% ZIP 5 s�F3Z
TENANT PHOr�: �0/2•SO/•G�O/d
CONTRACTOR NAME: � C..ri�
SUBMIT A COPY OF STATE LICENSE # � EXP DATE I� "'� I' I U
YOUR STATE yy�
LICENSE, BOND AND PLUMBING BOND #�J� ,� pl � i EXP DATE ��'" �I '� U
CERTIFICATEOF ADDRESS:��� C%7DK2 G%JC��/t/ �_ CITY n.�i�� L�'t.i STATE,�I NZIP5a�o38"
INSURANCE PHONE (f� I Z• -�-�2Z• 3t-/°/�1 FAX Ll /2 • 522 °�''�' °I 2.
PERMIT TYPE � INSTITUTIONAL O MULTI-FAMILY ❑ SWIMMING POOL
❑ TOWNHOUSE COMMERCIAL/INDUSTRIAL � OTHER
TYPE OF WORK: � �W �PLACEMENT ❑ ALTERATION/REMODEL
D T ILED DESCRI TION OF WORK 3 �% �� -�' y�Z�
FIXTURES: (INDICATE TOTAL NUMBER OF EACI�
CLOTHES WASHER _ FLOOR DRAINS _ RPZ VALVE _ URINAL
DISHWASHER _ GAS PIPING BACKFLOW PREV. _ WATER HEATER
DRINKING FOUNTAIN _ GREASE TRAP _ ROOF DRAINS WATER METER
FAUCET _ KITCHEN SINK _ SHOWER � WATER PIPING
FLAMMABLE WASTE TANK _ LAUNDRY TRAY _ SLOP SINK _ WATER SOFTENER
LAVATORY SWIMMING POOL WATER CLOSET
Total Job $`C .� All fees are based on valuation, including the cost of labor and materials.
Valuation
Permit Fee $_ i� (1.25% of Job Valuation / Minimum fee; $35)
Surcharge $ e� Valuation X.0005 or Minimum .50
Total Due $ V�•� Make Checks Payable to: City of k'ridley
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with 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 application for a permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in th e of all work which requires review and approval of plans.
SIGNATURE OF APPLICANT : PRINT N :��{ I C� 1�(/ VLY� DATE: I '�/ ''+ v
APPROVAL INSPBCTOR SIGNATURE: DA� � �"� �f
PLEASE NOTE: SEPARATE PERMITS A RE IRED FOR BUILDING, ELECTRICAL AND MECHANIC L WO
City of Fr' ley Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
0�