P - 36715From: 763 425 7461 Page: 2/2 Date: 4/5/2011 8:25:53 AM
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Building
Inspections
763-572-3b0�t
763-502-�977 FAX
aA� �� / J
PLUMBING
RESIDENTIAL APPLICATIUN
C�TY OF FRIDLEY
EFFEC'f7VC 1-1-2011
,�nn�ss
Yermit N
Received
D���'
sr�-� n�D�ss _I ?�7 r;_ � ;r�. ! � � Gc't�l �,�' ,
THiS APPLICANT (5: ❑ OWTtER OTFTRAGTOR
PROP�RTY NAME: Z i � 1`1 ,,,�/�,�
TE ANT ADDRESS: � Cd r CITY C� STAT�` I u ZIPS���
PHONE: �/ �it �j — . �,"�.I�u 2�.+ f�� �., �� �
COIYI'RACTOR NAt�: I r
SUBMIT A CC1PY OF
YC3UR STATE STATE LICEVSE # !� �I � ��;�� EXP DA7'�
L10EN$E, BOND AND STATE BOND N EXP DAi'E
CERTLFICA'I`F.Of ADDRESS: C' �� CI'CY C���C'CSt� STATf�'Y�J ZiP�.�
iNSlJitAI�CE PHOIVE 7(�i �"'S 71 �— G� �,S �' FAX _�ic7'� �' �i r� S— 7��,%
PERMiT TYPE � �SLVGC.E FA414ILY
TYPE OF WORIL• I� N�W
DETAILED DESCRlPT10N �F WORK
O TWO FAMILY ❑ TOWNTiOUSE
�REPLACEMfiN7
,
F�ES AS2E BASED ON 510.00 PFR �IXTURE, EXCEPT WHERE NOTED. FIXTURES: (lTialCATE TOTAL NEtMBER OF EACH 861.ilU�. M[NIMUM FEE
535.50.
BA'i'H SW K/i,AV FLOOR DRAINS SHOWER WATER PIPING
� 8ATH7i3B GAS PIPTNG (NE6D CITY L1C) � SWIlNMITfG POOL WATER SOFTNSit ($35)
CLO'tl-fES WASHER KTTCHEN S1NK W.ATERCL06ET BACiCFLOW PREV. (515)
� DIStl1�'ASHER �, LAUNpRY TRA Y _�VATER HEATER {$35) FOR IRRIGA'i701V
_ W Ai'EIt METER � O'17iER
Number of Fixtur�es Q S 1 Q.DO x S 10.00 = S
Number oFfixtures @ S 15.00 x$15.00 = S
Number of fixtures Q$35.QU x$35.00 =$
State Surcharge $ 5.{10
(bIiNIMUM $4Q.00) Total = $ "'! �+ � �'
"11-I15 IS AN APPL.iCATION FpR A PERMIT-NOT VALID UN'11L PROCESSED
I hereby apply for a plumbing pezmit and l acknowledge d�at the information above is compl�e and accurate; that dtc w�k wilt be in
conformar�e witb the ordinances and codes the C� f�ridley and with the Minnesota Consrructian Codes; d�at I unde�stand this is
not a permit but only an application for a p "t ork is ot to start without a pemtit on site; thai the work will be io accotdance
witlt the approved plan in ihe c f ali work ui ew and approv plans.�Q�,% J j % f
S[GN,4TUREOF APPL[CANT ���+t i. •RLNT NAME 1�G(I�Y �:_X rG L'}erA� DA7E �l�1 /I �--
PLEASE
II•.7��7
�---�-� City of Fridley
Buitding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
AI�D