P - 84365Building
Inspections
763-572-3604
763-502-4977 FAX �
DATE F�-I�'��q��
SITE ADDRESS , � 7a / `J[
THIS APPLICANT IS:
PROPERTY NAME:_
OWNER/
TENANT ADD�;
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENS�, BOND AND
CERTIFICATE OF
II*TSURANCE
PERMIT TYPE
TYrE oF woxx:
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EFFECTIVL 1-1-2012
YOUR E-MAIL ADbRESS
❑ OWNER Llt,`ONTRACTOR
��n�Car N'l�lara�S�,Jcc.r�/
�: G �1-R �'�� l�,Sa�i 'S#- 1'l1� ciTY
7le 3 - .?"'1/ - � 7 � 3 �
Permit No
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NAME: K(UL' � Ct +`-/ `� �lt/1�b t�
STATE LIC�NSE # P G �� a� J� 7 EXP DATE �
STATE BOND # EXP DATE _
AT$�_ZIP �y3 �`
ADDRESS:_� �G���% %YKt��I S�"• � CITY �/'� � IQV STATE�ZIP�lf.��
PHONE 76 3'7SY "� I-[ '�1 FAX -%�3- �'�J `i'� 02� G�
�SINGLE FAMILY
❑ NEW
❑ TWO FAMILY
LG�1£EPLACEMENT
Q TOWNHOUSE
DETAILED DESCRIPTION OF WORK Ks?..,(J I G.. cL° �.`�-2� j�C_r.l�-}-e('
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) SWININIING POOL WATER SOFTNER ($35)
_ CLOTHES WASHER KITCHEN 5INK WATER CLOSET T BACICFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
_ WATERMETER _ OTI�R
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 d with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and worlc is no o start ithout a permit on site; that the worlc will be in accordance
with the approved plan in the e all wor c equire • iew and pr f�I of pla
SIGNATURE OF APPLICANT PRINT �/'1(' � S �,0�7 n�TC lG '�� �' �/a---
APPROVAL INSP�CTORS SIGNATURE AD ' naTr- i� .n � n
��ty �f �radle�
�uilding �nspec�ions fl)e�aptment
64� 1 University Avenue NE, Fridley, MN 5�432
763-572-3604
FAX: 763-�02-4977
_ . _ _ _.