P - 48244�ualc�ing
Inspe�tians
763-572-3604
763-502-4977 F�iX
DATE 1 - �� � � �
SITE ADDRESS _
THIS APPLICANT IS:
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EFFECTNE 7-1-2010
YOUR E-MAIl ADDRESS
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❑ OWNER L�ONTRACTOR
�a�����z�� n�AME �Z�i t� �t' /7��►'
��WN��2/ ADDRESS: � CvYl'1 � CITY.
`d'LIoI�N'I' PHONE: �J�U� �-I CP�' o� f �
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Permit No.:<--
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ATEiMNLIP
COIVTR�C�F'�1�Z NAME: '
SUBMIT A COPY nF STATE LICENSE # {+ F',177(1 PAA ' E?�' DATE I r� "� I� I�
YOUR STATE
LlcErrsE, BorrD a� sr��rE s�� a 651-365-1340 �� LHT�
CERTIFICATE OF �DRESS: .3G7O DOC�CI RCI. CITY STATE ZIP
�rrsu�cE PHO� agan, MN 55123 F�
��&t1F�YI'T TYPE
'Y'YEE OP' S�'OI�K:
� SINGLE FAM1I Y
❑ NEW
❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
DETAILED DESCRIPTION OF WORK �CA.-�-t� � oCc,` /l� v�f aDl G; C� ���� "�
FEES ARE BASED ON $10.00 PER FUY"I'URE, E�CEPT WHERE NOTED_ FA'TURES: (INDICATE TOTAL NUMBER OF EACH BELOW). NIINIMiJM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER _ WATER PII'ING
BATHTUB GAS PIPING (NEED CITY LIC) SR'IMMING POOL _ WATER SOFINER ($35)
CLOTHES WASHER KITCHEN S1NK WATER CLOSET _BACKFLOW PAEV. (�1�)
v DISHWASHER LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
--" WATER METER _ OTHER
Number of fiatures @$ l 0.G0 _ x$10.00 =$
Number of fixtures (cr�, $15.00 _ a $15.00 = $
Number of fixtures (c� $35.00 _x $35.00 = $
State SurcharQe $ 5.00
(IYIIN�ATii71� $�0.00) Tota1= $ `���
THIS IS AN APPLICATTON FOR A PERMIT-NOT VALID UNTII. PROCESSED
I hereby apply for a plumbin� permit and I acknowled�e 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 nd work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the ca wo k v' and approv(l� of plans.
c*r:rr n�rt rtm c pF n,nnr T�ANT P;.P•v'T I': �^.� l�� Mn P`7 �7�� .-"•T� I s� ��� � J
.APPROVAL II�'SPECTORS SIGN �
'- PLEASE NOTE: SEP TE PERNIITS `ARE REQUIRED FOR BUILDING, ELECTRICAL P.ND MECH.ANICAL WORI�
�fi$�' �� �'�'llCAI��
��an�€�Ilng �������sd�s ��p�����rr�
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-�02-4977
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