P - 50473Fram: 8006042019 Page: 2/2 Date: 5l3/2012 9:29:46 AM
B5fQ3l12 18.'27:59 ET T�, t76�) SBZ-4978 FBOM: 8886842�14 �8Z
Building PLITMBIN(s Permit �o.� l� (Q I �
Ins�ections RESTDE111�TIAL A�'PLICATION i��i j��`
�6�-s�2-3�04 CITY C)F FR�DI.�EY Dat� R��°d:
763-SU2-4937 FA� ' �r�F.criv� �-�-aa�z
T1ATE .+�-- YtJUl2FrMA1LA[7bRESS �t�t("�'!C.'�"ff�l�'th35tJ i,�,,,��.(.. 1�
str�,�n�ss e-.vr+� c�.K S�`. 1G
THIS APPLLCAtd'f 35: C� OWNER �3(CONTRAC'TOR
ec�ori�x�rY Nan�: �✓"� �r,� � . /``� .�- �.�" ..�G./� -
OWNERt �up�s: ciTr srnr� z�t�
TENANT ,� , ., r� � a .., ..:.,, _ ..,. �
S[JSMTf A COPY OF .""1""�'""�"" _ _ f„ ..e
YQUR STAT6 �TATE LtCE $E #� ,� � � f (�� � � „� _ __, EXP DATE .+✓""�
LICENS6, $dTiD AN'D STATi IiOND # !�G �7 �4� D;iq,�,i��� EXP AATE +� , 1',�++ r
cExTtFtcATEOr nDOx�ss:��,,a'� 1�'`z. r��'"� �;� 1�,�.crrv�>r.�� 1'�d - f`.s�nr����r.�"..�' .�
INSURANGE PHONE � p� � "�x+° � � � � �J' FAx
PERMIi TXPE �SINOLE FAIv31:bY G3 TWO FAMILY O TOWNHOUSE
TXI'E OP WQRK: o r��w �x�P�.nc�rrr
DETAILED DESERIPTI�T�E OF WORK _��� �.a��,�;��.»: t� g �'.�. ,��' .�:��r� � ""�„ @ � .�" ` � ��,.�?�'� s�• .
�a
�h"ES ARE BASEi30N $SO.O� PBR RiXTURE,, EXCEP!T WHERE IVOTSD. FIXTURES: (�NUiCATE'f0'fAL idUMBFdt OF �ACYI $ELO�. MlNitv�tJkf PEE
S35.50.
BATtISINK2AV FLflURURA[NS SH4WER WATERPII'ING
_ BATH'fUB „j�, GA5 PtPihFG (C�fEED GITY L1G) '"� SWiMMiNG POOL �' WATER S4FTNER ($35)
�CLpTHESWASHER ,_,,,,KTtGH.ENSiNK WATERC;LOSFiT �BACRFL�WPBEV.($l5)
�„DISHWASi#Eii „_,_I,AUNDRY TRt�Y �WATER }iEAT£R ($35j � FOR IRRIGATION
„_,,, WATEIZ TvfETP.R _ OTHBit
THtS 1S AN AE'PLICATIpN FOR A PEKMIT-NOT VALID UNTII. PROCESSED
i hereby apply for a plumbing permit and T acknowi�ige thai the infarmaticm above is complete and accurake; that the work will be in
conformance with the ordinances and codes af the City oiFridley and with the Minnesota Construefion Codes; that I understand this is
not a peomi# but anty an applieation for a permit and work is not to start without a permit on site; thaf the work will be irn accordanee
with the approved plan in Eh;,.4c sse of all wor hich r�qnires review and appravat of p1an�
S[GNATUREOF APPLICAT�fT �ti��rt� � d�sn: � n.. PRINTNAME C� e.;,��. !rsl4C-f�-rJ DATE �/`p�.�,.I�'1r'Z.
City of Fridley
Buiiding Inspeciions Department
6431 University Avenue NE, Fridley, MN 55432
�63-572-36U4
�A:X: '763>502-497'1
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