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SITL 1DDRESS
TI-]!S APPLICANT IS
PR�P�R""�'
OWNER/
1'�NANi
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7 J�-i �A4�lS
0 OWNEK
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Pei-mit No.C�J
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ADDPL•'SS: �%S oi�% �,� �i � J S� 1J t CITI' F S"fATL �� �"LIP SS l(•� .�
PxoNC: 2c� 7�'a � a� �
CoN�'RAeTOR NAML: 12L.,-t..- CL�f � I �,.. ��+�
SUBMCf A COPY OF
YOUR STAT� STATL LICENSE # EXP DAT�
I,IC�NSE, I30ND AND STAT� BOND # EXP DATC
CERTIFICATE OF ADDRESS: e�9 O �-j wc,... ���, � CITY FR.1 d( �_ STATE n� zcP Ss 1�3 .L.
INSURANCE PHONE � L3'- �} S� �� 9, FAX �
PERMIT TYPE
TYPE OF WORK:
$ SINGL� FAMILY
❑ NEW
❑ TWO FAMILY ❑ TOWNHOUSE
/�REPLACEMENT
DETAILED DESCRIPTION OF WORK ,ZinJ�v � � �,t„r0 � L� C�t-tw�" (��q �,�,i ��E.,�,w,�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER,OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHVJASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
ii.iufurav.lri,.p-evwvj i Vtat — �D ' - -
THIS IS AN APPLICATION 1�OR A PERMIT-NOT VALID UNTIL PROCLSSED
1 hereby apply for a plumbin; permit and i acl<nowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of th City of idley and with the Minnesotl Construction Codes; that I understand this is
not a per�nit but only ai� application for a permit an war< is not to start without a permit on site; that the worlc will be in accordance
with the approved pla�l in the case of all �u rl< which re r s review and appr �al of plans. -
SIGNATURL OF n}'PLICANT �' PRI AMG �✓lV 2,vA p DATG •�
APPROVAL iNSP�C�'ORS SIGNA'fURE ��DATL-
PLEASENOTE: SEP;4R.�"['E'PER��iTTS ARE , .D F(�RBUILDING ELECTRIC�L AND P.�1ECT-TANI .,4I, QRK
�i�y �� ��-�dlew
�uiid � ��s�ec�ions �e�a�-fime�a�
6�}3 l Untversitv �venue :NE, :�ridlev, iVII'�] ���=432
763-�7?-�604�
t=f� :: 763-�0`'-4977
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