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Building
Inspections
7�3-572-360�4
763-502-4977 FF1.X
DATE �.� .� -. �_Z-.
31TE An�RESS ��f a i
THIS APPL[CANT IS:
PROP&RTY �A
OWN�xi/ AD
'I'ENANT
Date: 212112012 2:06:34 PM
�
�����X�[T Pcrmit No.; �ZG 1 S`�'�iSd.J. .
�������'��.� .t�,������.�'��� Received By'���
CITY OF F17.iDLEY �at��a:�-- �.- �� - �; � � �
cr.r.crTrvc �_� �ne� � . ^-
�,� YOilR E-MAIL
�%� 1V � �
CIOWNER j�pNTRACTQR
CONTRACTOR �AME: L) f111
SU8M1T A COPY OF STATE LICBNS�
Y4UR STATE
LIC�NSE, I30ND AND STA'I'6 �OND �
CFiRT[FICATE OF Ap��gs; G�
INSURANCE pMONE ! J�Z'
PERMITTlI�'E I ��NGLEFAMILY
TYP� OF WORI4s I � �E�'
DETAILED DESCRIPT[ON OF WORK
r
0 TWO FAM[LY
�#tEPLACEMENT
e
_CITY
_ FAX �SE
❑ TOWNHOUSE
���
fiXA DATB
IIXP DAT&
t. _ . �_.�_..
FEES ARE 9ASED 4h! 314,00 A6R FlXTURE, &XCEPT WHSRE NOTED. F[X'NRfi9: (INDICAT& TOTAL NUMHSft OF GAQIi f3ELOW). MINtMUM Ffi6
�3i.50.
_ DATH 3[NK/LAV _FLROR DEiAIN3 _ SHOWER _ WAT6R PIPIMO
BATHTIJB � GAS AIPiNG (NEED CCTY LIC) ,_,_, $WiMMiNG f'OOL � WATER SOIt['N8R ($3S)
^ CLOTH&S WA3H&R _ KITCHET7 BINK WAT6R CLpS�'t' BACKF40W PR�V. ($IS?
� DI3HWASHER _ LAUN�IiY TRA'Y WA7612 HSA'P6R (S35} POR IliltiGA7'ION
WnTSR M87'8R OTH81i
�
��I
'l'HIS IS AN APl'LICA'P[ON FOR A PSRMI'C-NOT VALID UNTIL PROCII55SD
I heraby apply for a plumbing permit and I acknr�wledge that the information above ia complate and eccurat�; that the wark wilI be in
conformanca with tha ordinancas and cades of the Ciry of Fridlay and with tha Minnesota Construotion Codes; that I undarstand thls fs
not a permit but only an sppticatio for a permit k is not/ �a st�rt wit out a permit on site; that the work will be in accordanca
withtheapprovadplanin e resxel+�IyNF A�lldlfLB�t•1e_D9lr.It.� rL �aTa Z.'��12.
SIGNATURk �F APPI.ICA %.i'��PR
City of �'ric�Iey
Building �ns�eotxoz�s �lepax�nr�ent
6431 Univ�rsity Avenua N�, �'ridiey, Mi�i 55432
763�572�3604
FAX: 763�saa�a9��