P - 467161.
�
F
� . �-
Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � — I o' ' I �
SITE ADDRESS _��Q
THIS APPLICANT IS:
O
' �g,��� (� Permit No.:!
�+ SII�ElOTTYAI� L�PPI�IC'L�T'IOl� Receivea B:
I.
i"ITY' O�'+ Ii' I�E+ �' Dat�� �
' FFFFrTrvF �_i _�m n
❑ OWNER '
��e
—
il�Vil+l�11 NAME:� � .VY � �
OWNER/ ADDRESS: -�.. CITY �� T/5/ STATE ��
TENA��TT PxoNE: iD�I'��3 � �, _ __, ,_
CONTRACTOR rr�: ?
SUBMIT A COPY OF STATE LICENSE # . EXP DATE i.� ' J' �. �(
" YOiTR STATE �IF �i�i�8-RI�VI
LICENSE, BOND AND STATE BOND # $��',1-:�Ei.�+-1''�dQ EXP DATE
ci�xTTr�cA�oF �DxESS: `' 3670 Dodd Rd.; cmr 'sTa� : z�r' �.. ''
�rsux�cE_ . PxorrE iEa�g�, MN 55123 Fax
PF�RMIT TYPE �INGLE FAMILY � TWO FAMII.Y ` ❑ TOVVNHOUSE
TYPE OF WORK: � NEW ' �EPLACEMENT
DETAILED DESCRIPTION OF WORK 1NIP',�,�--Pi�/ �et, Y'� �Q H"�r'�-
FE€S ARE �ASED ON $10.00 PER FIXTURE, EXCEPT �RE NOTED. FIX'I'[JRES: (INDICATE TOTAL N{JMBER OF EACH BELQVt�. MTNYM(TM FEE
$35.50.
_ $ATI� $R�K/LAV _FLOOR DRAINS �_ SHOWER _ WATEit PIFTNG
B?,THTUB GAS PIPING (NEED CITY LIC) SWIMNIING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DTSHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
THIS IS AN APP ATION FOR A PERIvIIT-NOT VALID UNTII. PROCESSED .. _
I hereby apply for a plumbing permit and I ackno ed'ge that the information above is complete and accurate; that the work will be in
conformance with the o�dinances an des of the ity of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a e 't work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case a v' w d appro��al of plans.
SIGNATURE OF APPLICANT AME :Jf�NY�P,G F�� �'I�41P�%DATE �1 �' ��
�'—�� City of I+'ridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
� d �o ���o c-f���
l