P - 35471From: 763 425 7461 Page: 2/2 Date: 4/4l2011 10:36:08 AM
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BU11C�ll1g
Inspect�ons
763-572-3604
763-502-497i FAY
DATE
srre ADa�ss�
THIS APPLICAIVT 15:
PROPERTY
OW�TER!
TENAIVT
PLUMBING
RE SIDENTIA►L APPLICATION
C�TY �JF FRIDLE�'
FFFECTIYE 1-1-201 ]
YOUR G-MA[f. ADDRESS
, 111_ tl . _ _._. 1 �l _..r..
C3 OWNER ��ONTRACTOR
�� u 'Y1,' s
SUBI►ill' A COPY OF ' ,
YOL'R STAT�'r. STA7� LICENSE #
LICEIVSE, BOND AI�TD SrATE I301�iU � V
CERTIFICATE OC ADDRESS:�{�
iNSURANCE
PHONE __ �%L
PERMTT TYPE I ��NGL� FAMILY
TYPE OF R'ORK: I a�'`��'�'
DETAILED DESCRIP'FION OF WORK
�
�
O'FWO FAMTI.Y
�REPLAC�A7�NT
Permit No.�
RBC�iVed By':
D��'4� �
` j� r ; c� (?�� sTa
)�
EXP pA'I6 ' =
EXP DATE
!f 3�.�.
f'Y C���SPC�' STATE�7.IP SS .� � �
�Ax 7� 3-'-�-� S - 7 �f-� /
❑ TOWNHOUSE
.� �
FEES ARE BASED OiV $IUAO PER F[X'CUR£, EXCEP'1' WHEItE NpTED. FlXfUltES: (INQICATE 1'QTAL NUMBER OF E.4CH BELOW�. VtMIMUM FEE
&35.50.
_ BA'CH StN[G'LAV FLOOR DRAINS SiIOWER WATER PIPiNG
BA7'H'F'UB GAS PIPING (NEED CITY LIC) �SW1MMiNCz POOL � WATGR S(3F7'MER (S35)
� CLOTHE5 WASH6R KITCHEN SINK �N%ATER CLOSET �SACKFLQW pREY. ($15J
� piSHWASHER � LAUNDRY 7RAY �W.4TER I•[EATER ($35) � FOR IRRIGATIO1v
� WATER h4E'['�R � OTHER
Number of ftxtures @ $10.00
l�Tumber of fixtares Q $IS.OQ
Number of f�xtures (a� $35.00
x SI0.00 = $
xS15.0(1=$
x$35.00=$_ _
Siate Sur�harge $ S.pp
(MIN�ML7M 540.00) Tocal = � � � ` Q G
THiS 1S AN APPLICATIOIv FORA PEFtMIT-NOT VALID tJIJ7'(L PROCESSED "'-.'�,_.—,
I hereby appl}� for a plumbing permit and I acknawledge that the information above is cornplete and accurat� that the work wiil be in
conformance with the orr�inances and cades of the City of Fridiey and with the Minnesvta Construction Codes; that 1 anderstend this is
not a permit but only an application for a per it and w•ork is not to start without a permit on site; that the work will be in accardance
with the approved glan in the c af all work ich 'res iew and approval of plans r- f
SIGNATEJRE OF APPLICA;VT � RlNT NAl�� mq �("� ��b lO�Y�DATE / J
APPROVAL tVSPECI'ORS SIGIVATU � �� DATE
PLEASE NOTE: SEPARATE PERMI REQLiiRED FOR BUILDING. ELECTRiCAL AND MECHAPd �ORK
Ciiy of Fridley
Building Inspections Department
G43 i University Aven�e NE, Fridley, MN 55432
763-572-3604
FAX: 763-�42-49?7