P - 48205Sullduag
Znspect�ans
763-5?2-3604
763-SOZ-4977 FA�
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TH{S APPI.ICANT IB;
OWNER/
�t`�1�1�#niT
SUBMiT A COPY OF
YOUR 5TATE
LCC�IVSE, BOND,AND
CERTIFICA7'� QF
INSUitANCE
PE�tM IT '�YPE
�'YPE OF WO�i,K:
From: unknown Page: 2/2 Date: 11/4/2011 1:47:06 PM
PLYJ��IN�G
RE�IDENT�A� A�Pi..ICA�'I'YON
CITY' OF F�ULE�"
_ Ek'FECTIVE 1.1-2011
�` YOUR �-Mr�IL AC1DR£SS
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G7 OWN�A �{CONTRACTDIt
SO V'�
Pexxzait No.: L 6 i� o � �
Received By:
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ApDRESS:�O. S�� � ��' 1 cal �,lf S "�" �CITY � �� �'�'� , STATE� P_ �� "T�
�HOr��: C2 t �.-- �'��O -��'�.3 $'
NAM�:�? ct t,.�„�` � C��-'�i m,�, � { .r �. b � v�� �. �..J' �-e�^ t# e �.#-�sr s , �. ir �.
STATE LICENS� # � (� � � �l' . . EXP DATE 11I.nz / � I j �� ( �.
STATE BOND # �� J�,, �1 S(Q ����Q EXP DATE _ �� � I r 2 4 f I
ADDRESS: � � � � `YO fti u 1 �, h. (�] CITY_, �. CR..� '�--� 1'\ S7ATE �� ZIP "�^�+ � � �
PHONECg�2��—�Q�CctQ � (►��{c>-$Y' FAX�.(��'a—��-�^G%4C1�
f�SINGLE FAMILY
❑ N�W
17ETAILEp pESCR1P�'ION dF WQ�t]�
i� TWO FAtvaILY
1�J itEPLA��MENT
❑ TOWNHpUS�
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FE�S A�tE gpSED pN $10.00 PER �I,(TURE, ExCEpT WHERE NOTED. FIXTURES: (INT?ICATE TOTAL NUMSER OF EACIi BELOW). M(NaMUM FEE
$35.50.
_ BATH SINtC/k,AV �k'LOOR DR.AINS „_ SHOWEit WAT�R PIFING
^, �ATH�UB CrA5 PCp1NG (PJEED CiTY L!C) SWIMMING POOL „ WATER SOF7N��t (53S)
_CLOTH'E$ WASHER � KITCHEN SI�IK WATER CLQS�T _ B.QC�tFLOW PREV. ($13)
,,,` J]tSHWASHER _ LA►�NX?RY TRAY TWq�'ER HEATER ($35) FOR lRRIGATION
_ WATER METER ,,,,," OTHER
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Number 4f fxture5.@ $�U OQ_� � �10 00 = � " .
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Nwnher of . .. ,..: -, ,
f�xhues $ I5:00 , z .
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` $1;�:�0 � .
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1�1su7n$er of fixtures (a� $35 00 � x $3S QO ' ��$ � �, a � ,
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State. Sttrcharge ' ' < . • ' .
$. �' 5 40
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TH[S 1S arr APAL1C.aT[ON FOR a P�RM1T-NOT vp„LID UNT1L PRpCESSED
i hereby apply for a plurnbing perm9t snd I ack
conformanee with the ordinanees and codes of �
not a permit but only an applicat�on far a perm
wit� the approved plan ira the case o�'all v,�ork w
$1GNATURE OF APFLICANT Q..�� �}-.� ��,
that the infarmation above is complete and accurate; that the work wilE be in
� Fridley and with the Minnesota Cpnstruction Codes; that Y understand this is
k is not to start without a pez�nit an site; that the worl� will be iq sccordanee
°es revaew and approval of p�ans, � � 1,� ), (
_„�,,,��1NT�h,IAM£��'�' I i'�Ckt"��^p�� �arF , � �
��-�-"'` CYty of k'ridley
�urxXding �nspectNOns Departme,�t
6431 Unive�szty Avezzue N'$, ��idley, M�1 55432
763-57�-3�04
�'A.�: '763-502-4977