P - 48161J ' � �
�uilding i���JI�[ � �l�T�
Inspections ������'��g� �����������
763-572-3604 ���� �� ������r
763-502-4977 FAX EFFECTIVE7-1-2010
DA'I'F � � I -t � �
SIT'E ADDRESS _�
THIS APPLICANT IS:
❑ OWNER
E-MAIL
Permit No.
Received By:
T_.._ T,...�.7.
---- - _
ENN�T ADDRESS: � _CITY � / STATE_ IP�
PHONE:---��y�,� / J� � .
CONTi2AC�'Ola N�:
SUBMIT A COPY OF STATE LICENSE # # fji 77Q-PM EXP DATE
YOUR STATE
LICENSE, BOND AND STATE BONU # gJ1-365-1340 EXP DATE
CERTIF'ICATE OF ,,,DDx�ss: 3670 Dodd Rd. CITY STATE z�
IN$Uf;ANCE PHOi�E .. elg�tl, FAX
PERMIT TYPE � SINGLE FAMILY ❑ TWO FAMILY ❑ TOVVNHOUSE
TYPE OF WQRK: ❑ NEW ' �REPLACEMENT
/
DETAILED DESGRIPTION OF WORK il�Gt,TVV �-� C�.�-P�( �I G-Lo —
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT VVi�RE NOTED. FIXTLTRES: (INDICATE TOTAL NUA�ER OF EACH BELdV�. MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER _ WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIIvIA�IING POOL _ WATER SOFTNER ($35)
CLOTE�S WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR gLRIGATION
WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII, PROCESSED
I hereby apply for a plumbin; permit an cknowle ae at the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of Ci of ridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a pemut wo is not to start without a permit on site; that the work will be in accordance
with the approved plan in #he c f 11 work �c es ev" w and appr 0.val of plans. _ 1�,' �_'�
SIGNATiJRE OF APPLICANT NAME -J_�i�Q� �'��� �]�✓ DATE 1
Ci�ty of �ridley
�ui ing Inspeetions Depart�ent
6431 Universify Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
�