P - 48604�uilc�ing
�ns�ections
763-572-3604
763-502-4977 FAX
DATE 5 `� � �
SITE ADDRESS �
THIS APPLICANT IS:
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SUBMIT A COPY OF'
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
12�TSUIZANCE
P�RI�F�'P '���E
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EFFECTIVE 7-I-2010
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❑ OWNER
NAME .�Q,r�
ADDRESS. G.
PHOIv'E: Vl �'
YOUR E-NLAIL ADDRESS
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CITY
Permit I�,TO.: �2��
Received By:
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TA'���ZIP���j
NAME: isil�iTl�l�si F'IIiCTl[alli��
STATE LICEA'SE # � EXP DATE � �� �
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STA1�E BONll # �G7n n.,.�a.� R,�E 'chr DATE
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ADDRESS: ��py R/IN ��,'� �:'' CITY STATE ZIP
PHONE
�INGLE FAMII.Y
FAX
❑ TWO FAMILY ❑ TOWNFi0U5E
`TYP� O� RvVORI{: ❑ �W �PLACEMENT
DETAILED DESCRIPTION OF WORK
I FEES A£�E BASED ON $10.00 PER FUYTiJRE, EXCEPT WHERE NOTED. FTXT"URES: (INDICATE TOTAL NUMBER OF EACH BELOW). NIINIMUM FEE
�35.50.
BATH SINTVLAV FLOOR DRAII�TS SHOWER WATER PIPING
BATHTIJB GAS PIPING (NEED CI'I'Y LIC) SVJIIvIIv1ING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACI:FLOW PREV. ($1�)
DISHWASHER _ LAUNDRY TRAY I WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
Number of fixtures, @ $10.00 x $10.00 — $
Number of fixtures (c� $15.00 a $li.00 $
Number of fv:tures �a, $35.00 S x $35.00 — $ � '�
State Surchar�e $ 5.00
(1'�'YINY1WYi71�✓g $40.001 Total $ '"f � ' �
THIS IS AN APPLICATION FOR A PERAdIT-NOT VALID UNTII. PROCESSED
I 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 the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for ermit d��ark is ot to start without a permit on site; that the work will be in accordance
with the approved plan in the case of.all �uo a a r� al nf plans. ' ( f
SIGNATURE OF APPLICANT % '� `` N.ANIE �t•t�4h�.S ��ATE q'� \� � 1 ? '
APPROVAL INSPECTORS SIGNAT
PLEASE NOTE: SEPARA PE ,ARE REQ D FOR BUILDING, ELECTRICAL AND 1��CHANICAL WORIt
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��i�d��g ���ge��s�r�s I���a�r�r�zer��
6431 University Avenue i�TE, Fridley, MN 55432
763-�72-3604
FAX: 763-�02-4977
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