P - 37123From: 763 425 7461 Page: 2/4 Date: 1/28/2011 9:12:58 AM
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Building �Tu�.i���s Per3nit tila.: � .
Inspe�tions RESII)ENTIA►.L A.PPLICATIEJN Received By;���
763-�72-3G04 C;'�`� ��i FR�L�� Dat���= �
763-502-4977 FAX EFFECTSVE I-l-?01 l
SITB ADbAESS
THIS !�PPLICANT IS:
PROPERTY
OVYIYER/
TENANT
CONTRACTOR
SLf$i�4iT A CUPY OF
'YOUR STATE
LICETISE, BQND AlvD
CERTIFIGA"1'E OF
INSURANCE
i PERM[T TYPE
.�1 I r
r qd ��`,
❑ 01YNER I
VAME:_�=�.1—�
ADDRESS:�_
PHQNE:_____�t�=
NAME: �
STA'i"E LiCENSE #
STATE BQND #
ADDRESS: � 3
PHOFlE �.ZL
I�S]NGLE FAI�7ILY
TYPE OF WORK: I � �w
DETAILEDDESCRIPTIO,N OF WORK
YOUR E�MAIL ADDFiES
��.'� �� �-�
JMI'RACTOR
c�e h�e,�'
�i'�'S :: -�zs n c�.
3�-'77s�-
���. '
hp �
l E'��V��i ���L!
� 7�-.-� �'—`��!
❑ TWO FAMILY
�REPLACEMSNT
�
� r' P � �.
u � �^�..,�
EXP DATE ____�_�7
EXP DATE
u y �j<� � ST�
� FAX _ �li^ . � `" ��� S
❑ T4WNHUUSE
r' ! ,. _ __ ,- .-!.
PEFS ARE BASGD ON $1o.00 PER FIXTURE, EXCEPT WHEEtE NOTED. PI7(TURFS: (INll1CATE TOTAL ?�fUMBER aF EACL•I BELOVb'). MINIMUM FEE
$35.SjJ. SFtd4YER WATER PEPING
BATH SiNIG�L.AV FI.QOR DRAiN5 —S��fN(i PflOL � WATEEt SOFTNER(S35)
�BATHTUB GASPIPING(NF..EDCCTYLIC) —WATERCLOSET �BACKFLOV�PKEV,($1Sl
� CLOTHL-S WASFiSR _ SCITCHEN SINK "—"yyArER H6ATER ($i5j � FQR iRRIGA770N
� DfSHWASHfiR T LAUNDRY 'fRAY —. �.rn�
— WATER ME"lER �
Nacnber of fixtures aQ $]O.OD
Number of fixtures � �I5.04
x �1U.40 = �
x �15.00 = $
Number of fixtures @ �3SA� x $35.00 = $
State 5uccharge
$ 5.00
INIlNtUM S40A0 Tota1= $ �• d �
THI515 AN t4PPidCA'I10N FOR A PE32MIT-NOT VALCD UN17L PROCESSED
I hereby apply for a plumbing permit and I acirnawiedge that the infarmation aboxe is complete and ac.curate; that the wock will be in
conformance with the ardinances and codes of the City of Fridley snd with the Minnesota Construction Codes; that I understand this is
aot a peemit but only an aQplicatian for a permi d work is not to staut without a permit on site; that the work will be in accordance
with the approved plan in th se of ali eq evietiv and approv t of lans �y I ��AT6
51GNA'rUR.6 �F APPLICANT PR1N'1' NAfv1E
_ ___ /� DAT£ ' , ' ^
City Qf Fridiey
Building Inspec�ions Department
6431 University Avenue �IE, Fridley, MN 55432
7b3-572-3644
FAX: 763-502-�977
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