AF - 47238/� .
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. �:ec�:trr r•or� c:��rrit�rcn�r�i OC TI'Ct,e: . � ' • �
. %..� �" 07 / . � .19%/�
• I:eccived of 'fl�e C;Ety of Pxidiey of �lnoka Counfiy, biinnesota, O��ner's Duplicate
Certific� te af Titic No. �� �� 7 � �_ .
i9}tness�s
s��n1•l: o r_s��.L�1y�5' o i z2. � � � s s. �
County cf /lKJO/�� • ) . '
T� . . .
Qn t}i:is �� day of �D�G`�/�7BF-•f', A.D. ?9 �J , 1>efc?re me, a
Notarv Public �ritttiii an:! foi� said Ca�iiii:y, personal.ly appeared
._,C_.� �'d f�7.2 � � �C�7 . � tfiflSoti _. ...T_.. - -
to mc }:�.o,�m to bc the perso;i�described iii and i•aho executecl the f�rcgoing i.�!stxi�ment
and tick�.o:�.=Iecltied that hc_er.ecuteci tiie sar�e as . h j,�� fra act ar.d �t�ed. .�•
_... _�''/�ia/� ' .
/
_� °`r" ' _.�.__ .
• � ��W�^� C�YDE, V. MO�tHVE.r��
,,��- it,���. � .
� �") , �,� ,����. IV�TAPY Put3Ll� h11NiYESQTA ^ .
�Fj'%�.� � "-. �,�,. �. �J/ , � �.��� �� ANQhk CGuNTY
•��mission E:c��,•2; u; �. 2�, l a;G
. . � . � `�sd'�? ... � .'�frSVN'��+"�v.,a _ . .. . . � . . . . � � �
� ,�( % l�f ! �' ��2 y �7-��: � �~'
SUBJECT IT .
c�ty of Fridley o-17 2 3 2
AT THE TOP OF THE TWINS g U I L D I N G P E R M I T
r
' ' R
� � .
�
• COMMUNITY DEVEIOPMENT DIV.
� � �: ----- �
r � � PROTECTIVE INSPECTION SEG /D �'% r%
1 � � � � !
�
l-__- �;�'���;,� CITY HALL FRIDLEY 55432 NUMBER REV. DATE PAGE OF APPROVED BV
t J` 612-571-3450 9�0-F15 g���83 / /
JOB ADDRESS 6817 Hickory Street N. E.
1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
oescR. 3 2 Ostnian � s Fi,rs t Addition SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Helen Johnson 6817 Hickory Street N.E. 571-1951
3 CONTRACTOR MAIL ADDRESS ZIP PHONE UCENSE NO.
Same
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE �ICENSE NO.
5 ENGINEER MAILADDRESS ZIP PHONE IICENSENO.
6 USE OF BUILDING
R,esidential
7 CIASS OF WORK
❑ NEW ❑ ADDITtON ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
X
8 DESCRIBE WORK
Reraof Dwellin
9 CHANGE QF USE FROM TO
STIPULATIONS
13oof can be the 2nd la�rer but not the.3xd< Install ridged galvanized va3.leys.
TYPE OF CONST. OCCUPANCY GR�UP OCCUPANCY LOAD
SEPARATE PERMITS ARE RE�UIRED FOR ELECTRICAI, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOIO IF WORK OR CONSTRUCTION ZONING SQ. FT. CU. FT.
AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENOED OR ABANOONED FOR A PERIOD OF 120 DAYS AT
ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINEO THIS APPLiCATION �- STAILS GARAGES
AND KNOW THE SAME TO BE TRUf AND CORRECT. ALL PROVISIONS OF LAWS VALUATION SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WI�L BE COMPLIED $].�300 $•65
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOIATE OR CANCEL THE pERMITFEE SACCHAFiGE
PFOVISIONS OF ANY OTHEF; STATE OR LOCAL LAW REGULATING CON- $`22 � OO
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
PLAN CHECK FEE TOTAL FEE
$22.65
` , SIGNATUREOPC�r OAAU HOR12EDAGENT �Dn7Ei - _ q1/HEN PROPERLY V DATED THIS IS YOUR PERMIT
J� � y3 � h � �7 P.3
SiGNATUREOFOWNERiIF BU�LDEAI IDATEI BIOG �NSP �A E
CiTY OT FrzID�[Y
tit'PLICIITI0:1 FOft RCSIDL'i��T1P.� QUILDI��G P�('v�ITS
(Nert, A1 ter�tions, Additions, or Rc�airs)
�
O��NER:��'C''c �.'G- `l`i � O� N S C�"!J
ADJP.ES S : � � � � � o�-
TEL R0: �'� � — \� S �
STItITST AIO: � \
STI2EF.T:
�[3UI LDER ;
ADDftCSS;
TEL t10:
Construction Location
L07 : BLOIX: ADAITIOiJ :
Effective Aug. 1, 1981
Corner Lot: Insicie I.flt: Setbacr.: Sideyaxds:
Ap�licant attach to tliis form two Certificates of S�rvcy of lot and
pzoposed building location drawn on certificates to scale.
DESCRIPTIO�� OF COi�lSTFUCTIOt�
Front: Depth: Height:
Squarc Feet: Clibic Feet:
Front: Depth: Height:
Square Fe�t: CUbic I'eet:'
aype of Con�truction :��c —�. f� v�' EstimaLed Cost: S��b �� � �
Zb Be Cbr.�pleted: �0
Alt. A Alt. B
Propos�d Driveway Hidth If New Openinq Is Desised: $ $
S�� PEVF:lL?: SIDi OF StIE�T
9S�e undersigned hereby ma1;c� appliclticn for a perrcit fcr the �:ork herein sp�cified,
agreeing to do .all �:ork ir� strict accordance �rith the Ci�y of I'ridley Ozdinances ��id
zuling� of tl�e Departm��t of IIuildings, and hereby declares that all tl�e iacts and
represc� t,.ltiens stated in this a,nnlic�tion are true and correct.
� ` � ` �� � r
Stil�ulaCions :
��a��v
,��
�a �s
�
.
s
�
%\
SIAi� (� MINhESOTA DEPARIP'�NT OF HEN.TH
ABANDONED NELL RECORD
1. lOCA110N OF IIELL
County Nea�e
AI10�:d
TownsM p M�ne TownsM p Nu� Range NumDe� Sectton No. Fractlon
N E 4 y of 9
Fridley 29 °' 15 NE NE
Numer Street Address and C1ty o/ Well Loc�t on or Distane� fro� Road
etersectton
6817 Hickory P1.
Show exact location of
�
'x') Sk�tCh ap of w�il ioutlon
r-- 1 .i L —
2. PROPERTY OYNER'S NAl�
Helen Johnson
E N
ti �a. �3�
1
ic cory Pl .
Meiling Addre�s if dtfferont tMn
property address indic�ted aAow
HIIROIIE55 Of
3. FORMIITiON LOG COIOR FOIUtl1T10t1 FROM TO
1f not known, tndle�ta fonnation log fros new weii o� ne�rby w�ll.
MINNESOTA UNIQUE MELL N0. •
(leeve Alank if not known)
4. WEII DEPTN (eonipleted) Oate se�led
114 rt. 4/?..n/90
5. DRIILING METH00 (if knmm)
1� Gbl� tool � Rfv�rs� 7(� DHren 1� Duq
sp Noi�or aoe sp A�� ep eorea i�p
3� Rot�ry 60 Jttted � iawer Aug��
6. OBSTRUCIIONS
Netl obatrocted� Yes ❑ No
Obstruet/ons nwovM � Yes ❑ No tf obatratlons eannot be
re�ovW. contaet NDH
fon snling.
• 1�Oo�estle {] Monitor/ng � INat Loop
2[� t��ig�cion 5� vuette 90 indu:t�y
3� Test 11e11 6� Muntelp�l 1� Cow�eret�l
, 7[] A1� Coedlttenlnq 11[]
8. [JISIN6(S)
� �� 91 ack � Thre�dM 7(]
ap wi.. ep w.ta.e
� vt.aNe 60 statnle:: steel
1n. te ft.
in. to ft.
9. SCREEN
� Seretned wll frow _ ft. Lo ,�_ ft.
( if knorm )
❑ Open Xol� fro� ,_ ft. to �_ ft.
10. STAT C W R LEYE� '
ft. Wiow � �bow
laed suM�e� �te Measund
11. MELLMEAD COMPlETION
1� P1tl�ss AMpter
� Bas�nent effs�t
3� Neii Pit
� Foww eurtw b VT' S� a�
�
REX11RK5. ELEVATiON, SOURCE OF QATA - CASiN6S RElIDVED, CASiN65 PERFOIGTED. ETC.
12. GRWTIN6 [NFORlNTIOtI
2�� 4Te11 � 114 � aeep in front Of �'lOUS2 � Neat Ceeient 2(] BentoMt� �
6rout �uNal fro� � Lo�� " ft. cu. yds_
Buriec� 5 Z feet c.eep. � —
13. NEAREST SOURCES OF CONTAMINATlON
, feet direeNon type
Bell;dlsintected befow sea11ng1 ❑ 1es
iFFiCIA� ABANpONED YELI RECORD (May be used for iro0erty Transfer)
L�QtT11lli's 1►ZLS NZ?!P p�
14. PUMP j5d Reaoved [] Not Present
r�
Type: 1Q Subw�nlble �] L.S. Turbine � Reciprocating
2j�Jet � C�ntrlfuqal EQ
I5. ExJST7116 I�LLS (r1NSt sbtc� locatia�s Of s�NnneA �aA
•etiw weils in re�n�kf s�e o o� on baek.)
Othe� um�sW wNl(f) on Orop�rty7 � Yp Ib
AbandoMd: � /�rw�n�nt ❑ Ta�por�ry � t e�i�d
17. WITER NELL CONTRACTORS CERTIFICA7ION �
TAtz well was sealed under ry jurisdittion and tMs repo�t i
ts true to the best of wr knavledge and b�iief.
L
Address � � O I.,a.
5lgned � �L �_Date �
O�L�
N�ae o1 Ortil��
NEw I1
ADDN [ ]
ALTER [ ]
CITY OF FRIDLEY
SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMITAPPLICATION
,_ __
. _,
,�-�t �`s ���;�5,�;
Effective 1/1/2001
(763) 572-3604 Bidg Insp
Construction Address: (� k� r% t-t 1iCk.Gl2.V ��{-. /U�
Legal Description:
Owner Name & Address: ��� r` �C �i h o�p o rl�'C�, �d �s � h .,�e'� Tel. #_ %!� 3- � 4S- �� �`�'1
Contractor: `S�� T v�r� MN LICENSE # c�O(��,i� �%c� %
Address: �C�(o 50 Cr�. �$L �'�05 iMn��P QQcg �re hA � 553� � Tel. #?/�3-3� ✓'g4d�o
IIVING AREA:
GARAGE AREA:
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
Length Width Height Sq. Ft.
Length Width Height Sq. Ft.
DECK AREA: Length
OTHER:
Width Hgt/Ground Sq. Ft.
Construction Type:�-QG �-� 4-�� 3�-l26'O� Estimated Cost: $�� � �. C�C�
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x$ _$
DATE: � 4� APPLICANT: ���(� A�@�I Y�lQ� Tel. #?�3 3 I�� Rb (�
CITY USE ONLY - Call (763) 572-3604 for Permit Fees if mailing in application
Permit Fee $ �3. �S Fee Schedule on Reverse Side
Fire Surcharge $ �, 3 at .001 �f Permii Valuaiion ('ifl0tn%)
State Surcharge $ L, l C� $.50/$1,000 Valuation
SAC Charge $ $1150 per SAC Unit
License Surcharge $ 5,b� $5.00 (State Licensed Residential Contractors)
Driveway Escrow $ Alt. "A" or Alt. "B" Above
Erosion Control $ $450.00 Conservation Plan Review
Park Fee $
Sewer Main Charge $
TOTAL
STIPULATIONS:
� �l � , `7 �o
.Fee Determined by Engineering
Agreement Necessary [ ] Not Necessary [ ]
3uilding
nspe�tions
163-5'�2-3604
)ATE '� ��� �` � ;�. r�
,ITE ADDRESS r ^ � % 4
'H1S APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
WITH APPLICATION
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MAIL ADDRESS _
r. .,
1� t f �h.:✓ �, � ' ��\. `
❑ OWNE ❑CONTR.ACTOR
rt. c:' �, �� l� c 7� �.•. �`�.1�
_ f a.j i�-1 � 1
Permit No.O
Received By:
Date Rec'd:
♦ \�/� . ,. _-,
� ` � � �^� �-
ADDRESS:� -� � � +�[ �Gt, v� `a f ,ti�i.� CITY �"" ',�. I (� STA7'E�,�IP '� 1 � S C
PHONE:1'7 - 5� ��7 I�- 3 � E. �
NAME:i,� �g i` �C = C.-#�=�-t �•� I� L L- �.�'�y ��'
STATE LICENSE # EXP DATE
ADDRESS: CITY STATE ZIP
PHONE FAX
I�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ DECK
�
DESCRIBE WORK BEING DONE:
SIZE OF IlvSPROVEMENT
� GARAG
FINISH ❑ ROOF
❑ SIDING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Viny]
O A]uminum
❑ Other
WINDOWS
IN EXISTING OPENINGS OYes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
ALL FEES ARE B ON V.
Pernvt Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
C�Zrb Ciit Escrow
Erosion Control
Pazk Fee
Sewer Main Char
Total Due
JOB V
�
LENGTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATIACI�D GARAGE
❑ DETACHED GARAGE
�Soffit
❑ Trim
❑ Fascia
LACATION OF WINDOWS
TION, INCLI
� � E�9 �
❑ DRAIN TILE
❑ OTf-IER
� . � / 7
S-l� �'�s w ; � V � .
�
o c� ti"� �n —F�-lti t��-1 Q 11� �.�7�'
WIDTH HEIGHT Sq. F�
BASEMENT REMODELING SUBMTT•
1. Facisting Floor Plan
2. Proposed floor plan
3. List of s ctural members to be used
}�u�l(� 2 fOvr'Y�S
FQRI�IEW CONSTRUCTION INCLUDING DECKS,
A�DTfIONS & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project
2. Two sets of constvction plans
3. En�rgY Calculations
AND MATERIALS:
TYPE
$ See Back Page fo chedule •7G 3 2�} s�- � O�
$ sy ,/ 65 0 o uilding Perniit Fee
$ �, �/5 .001 times the total job valuation �
$ � , .0005 x Permit Valuation Minimum $.50
$ $5.00 (State Licensed Residential Coniractors)
$ $1550 per SAC Unit (Plans to MWCC for deternrination)
g ft+6ft= ftx$20=$
$ $450 Conservation Plan Review
$ Fee Detennined by Engineering
'—"1$ ' Agreement necessary ( ) Non Necessary ( )
�_ O,3 $,� � Q� Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclaiowledge that the information above is complete and accurate; that tkae 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
perinit but only an application for a permit and work is not to start without a permit; that the work will be in accordance with the approved
plan in the case of all work whicl�equires review and approval of plans.
SIGNATURE OF APPLICANT -� �,� : ���i��` _PRTNT NAMEi�I� C- 1 I C �''I i�(� ' C:2.A�,j�ATE b� I� S� J���
S �
✓
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REVtEWED ,�
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it
� Building MECHANICAL Permit No : 'U l�1
Inspections RESIDENTIAL APFLICATION Received By:.!'�'�
763-572-3604 CITY OF FRIDLEY Date n �i /17 �n
763-502-4977 FAX EFFECTIVE 1-I-08 �E��� 9
DATE D e C 2 9. 2 O 0 8 YOUR E-MAiL ADDRESS
SITEa,DDRESS 6817 Hickory St . NE
THIS APPLICANT IS: O OWNER �7CONTR.4CTOR
PROPERTY NpMg: Eshraga Omer
OWNER/ pDDRESS: 1 C O T y t. CITY F r i rl 1 a� STATE�]�ZIP S 5 G3 2
TENANT PxoNE: 763-245-9869
CONTRACTOR COtvtPa.NY NatvtE: A n d e r s o n B u r n e r S e r v i c e, I n c.
NOTE: � r r � :- �-, t , � , . i . �' �-
SEPARATE CITY CONTACT PERSON: . , a �' g� ' ' '�3 ` -
LICENSES ARE STATE LICENSE # 5 5- n n 2 n fi EXP DATE 1 �-1 A-(1 Q
REQUIRED FOR GAS �DRESS: 1 7 5 3 5 Ch i s h o 1 m S t. N E CITY H a m L a k e STATE j� j(_Z[P� S 4 n 3.
AND HVAC.
SUBMIT COPY OF BOND pHONE 7 h�- L� /. - h/, h 4 F� ? 0���.4, �� ti�
AND MSURANCE
PERMIT TYPE • � SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK• � NEW I� REPLACEMENT ❑ ALTERATION/REMODEI.
DETAILED DESCRIPTION OF WORK r e p 1 a c e e x i s t i n g f u r n a c e
PER MS 16�.665 the permit fee is a minimum of $15.00 or 5% of the total cost up to $500.00, whichever is greater, for the
improvement, installation or replacement of a residential fixture, excluding the fixtures. (This should reflect only the cost of labor )
OR
Labor cost under $300 =$I5.00. Labor cost between $300 to $500 = cost of labor x.OS =
FOR PROJECTS WHERE LABOR EXCEEDS $500, FEES ARE BASED ON $]0.00 PER FIXTURE, EXCEPT WHERE NOTED. F[XTURES: (MDICATE TOTAL
NUMBER OF EACH BELOV�
Equipment installed MFG: F. v r n n MOD�E;�g,g,�,��MP 1 1 SIZE/B���,_
MFG: MODEL: SIZEJB
MFG: MODEL: SIZEBTU
A/C $25.00 FIREPLACE (GAS) $15.00 _GAS RANGE/OVEN 510.00
AIR TO AIR EXCHANGEER $15 _FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOiLER $35.00 �FURNACE $35.00 _GAS UNIT HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00 ,
DUCT WORK $10.00 GAS PIPING $l0.00 _VENTiLATOR $I5.00
Permit Fee � 5. 0 0 . Number of fixtures @$10.00 x$10.00 =$
Surcharge $ .50 Number of fixtures @ $15.00 x $15.00 = $
TOTAL DUE ` $ � 5 - .�� OR Number of fixtures @ $25.00 x $25.00 = $
Number of fixtvres @ $35.00 x $35.00 = $
State Surcharge = $ .50
MINIMUM $15.50 MINIMUM $15.50 Tota1= $
THIS IS AN APPLICATION FOR A PERMTT-NOT VALID UNT(L PROCESSED
I hereby apply for a mechanical 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 permit and work is not to
start without a permit; th e work will ' accordance ' the a� e case of all work which requires review and approval of plans.
SIGNATURE OF APPLI PRINT NAMEH o w a r d A n d e r s o n DATE 1- 5- 0 9
APPROVED BY DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
Date: 1/4/2009 Revision Date: 1/4/2009
Site Information
Address 1: 6817 Hickory St.,NE
Address 2:
City: Fridley County: Anoka
Application Information
Business Name: Anderson Bumer Service, Inc.
Contact Person:
Office Ph: 763-434-6464 Fax: Cell Ph:
Address 1: 17535 Chisholm St.,NE
City: Ham Lake State: MN Zip Code: 55304
Existing Construction: Pre 1994.
Project #:
Lot: Block:
Subdivision:
MN Contractor l.icense #: 55-200208
Combustion Appliance
Water Heater: Natural Draft Input BTUs: 40,000 Common Vent
Fumace/Boiler: Fan Assisted Input BTUs: 80,000 Common Vent
Make-Ua Air
No Make-Up Air Required by Code
Combustion Air
Minimum Combustion Air Requirements Met.
Applicant Name {print : Anderson Burner Service, Inc. )
Signature/Date: January 20, 2009
Code Official (print):�_ _.
Signature/Date:
0 2004 CenterPoint Energy Minnegasco. 2004 Mechanical Code Guidelines. Page 1
�� U�J�� �,
Building PLUMBING
Inspections �SIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 7-1-2010
DATE C7
SITE ADD S �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
L■
YOUR E-MAIL ADDRESS
,r�' /�-!<=`—`
r
pHOt•rE: 7��–°S`�7l �306 7
STATE LICENSE
�^ ��
Permit No.:
Received By:
,
Date Rec'd: U
' STATE ZIP
EXP DATE
STATE BOND # EXP DATE '
ADDRESS: K�'4i a'a'✓ CITY �� STA�r/'��ZIP�,�
PHONE 7� ;� � OZ ► �'-� �YoL.� �" FAX % t l�— ,�.�OZ ' G�Q7:�
(�SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � ��' �CEMENT
DETAILED DESCRIPTION OF WORK � �
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BE1AW). MINIMUM FEE
$35.50.
BATH SINK/LAV _FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER (E35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. (SIS}
_ DISHWASHER _ LAUNDRY TRAY 1WATER HEATER ($35) FOR IltRIGATION
_ WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing 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 permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in e s f a wor �res r�view and appro pl ,_/
SIGNATURE OF APPLICANT ,/� ,r��������� PRINT NAME �� � ,� VC /�''� DATE� t CL�
APPROVAL INSPECTORS SI AT J�tE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977