P - 48243�
�uilciing
Ins�ectians
763-572-3604
763-502-4977 FAX
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EFFECTIVE 7-1-2010
DATE__ I�'c� l_�- � I YOURE-ivLAILADDRESS
SITE ADDRESS S� C �� I ZC.�✓� �� ��
THIS APPLICANT IS: ❑ OWNER [1�CONTRACTOR
Pernlit No.� � �� ��
Received Ry: _��
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P������Y nrA�: � a� k- ��� r� S�v�
��IVt$N�d' ADDRESS: ��%WN `-� 2 CITY �'� 1 � �� _STATE�l"�IP S,rcZa-
PHONE: �"��5� � " ( ✓( ii
�'Q'�?T8'`�.c z Q�. � NAMt: �',i19 1C1re �111mhir�� /
SUBMIT A COPY OF STATE LICENSE # # 617i0-PI�f EXP DATE ��-��� � 1
YOUR STATE
LICENSE, BoND ArrD s-rAr� sorrv � 651-365-134C t� L.�.i�
CERTIFICATE OF �DRESS: DOCIC� RCIe �ITy_ STATE ZIP
INSURANCE PHONE ' � F�
���,��T. .y.�,�� /�SII�IGLE FAMII,Y ❑ TWO FAMIL.Y ❑ TOWNHOUSE
TYPE OF WORK: � �W ��PLACEMENT
DETAILED DESCRIPTION OF VJORK �� �S � � (U ��- � ����
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT VJIIERE NOTED. FIXT'URES: (INDICATE TOTAL NUMBER OF EACH BELOW). NffNIIv1IJM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) S��IIvIIvffNG POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK i WATER CLOSET BACKFLOW PfiEV. ($15)
DISHWASHER LALINDRX TRAY WATER HEATER (�3S) FOR IftRIGATION
— i WATFn iv"-.cTEh' _ OTF-T.ER
Number of fixtures @ $10.00 _ x $10.00 — $
Number of fLYtures (a�, $1�.00 _ x $1�.00 $
Number of fixtures (a� $35.00 _'x $35.00 — $
State Surcharge $ 5.00
(1VIdNIIF'�i71�'d �40.001 Total $ � �e �J
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII. PROCESSED
I hereby apply for a plumbing permit and I acknowled�e that the infoirriation 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 the ca o ark�� �h r review and approva1} of plans.
SIGNATL'P,t CF ?.I'FLICr.:IT ���'� . N.viv� J cwhPS �-r 4`Ke�r Lnl E 1.'s � i-/ r
APPROVAL INSPECTORS SIGN
-.`PLEASENOTE: SEP TE PERMITS.ARE REQUIREDFOR BUILDING, ELECTRICAL AND MECHANICAL WORI�
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I�t���e�inb �t�s�ectiar�s ��p��°��e��
64� 1 University Avenue NE, Fridley, MN 55432
763�572-3604
FAX: 763-�02-4977
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