AF - 41658�uilding
Inspections
763-572-3604
763-502-4977 FAX
DATE � � I D
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMTI' A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
�rE oF wonx:
�L��ING
�S�EN'I'�L �PI.,�tCt�'��Ol�T
.J
���� �� ������
EFFECTIVE 7-1-2010
❑ OWNER
NAME: �
ADDRESS: Bi�S"
PHONE:�1o�
NAME:�
STATE LICENSE #_
STATE BOND #
ADDRESS: �L�O
PHONE��
�SINGLE FAMILY
, .,
❑ NEW
DETAILED DESCRIPTION OF WORK
YOUR E-MAIL ADDRESS
Y /U �
CITY_
FAX
❑ TWO FAMILY ❑ TOWNHOUSE
Permit
Received By4`. ►
Date��Q JUL 1 ��a
2
EXP DATE
EXP DATE
� STATE�ZIP_Sr� ` f �/" .Z
FEES ARE BASED ON $10.00 PER FIXTIJRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVI�. MINIMUM FEE
$35.50.
BATH SINK/d,AV FLOOR DRAINS SHOWER WATER PIPING
BATfiTUB GAS PIPING (NEED CITY LIC) SWIMIVIDVG POOL WATER SOFfNER ($35�
CLOTHES WASHER KITCHEN SINIC WATERCLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR II2RIGATION
_ WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plutnbing 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 pemut and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the/Q �e��; a11 'ch requires review and approval of pl ������
SIGNATURE OF APPLICANT �i,l�:v"� � � PRINT NAME �1 l�(L a��w"�Y/'QN DATE � C� ��
♦ nnn�<s � t n.renan�r�no C�T!!1�T A TT TDL' _ R. � a�1 7�31_ M
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977