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Cu7N',*'i I�iG'�'OR
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YOUR STATL
LIC�NSE. BOND AND
CERTIriCATE Or
1NSURANC�
PERMIT TYPE
TYPE OF WORK:
°ermi�
�;eceivec: 8��:
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��our: L-��-i�+�� ao���ss Cf� r� s��op�'�c,u.�s-fo�rc 2• 11e- f
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❑ OWiJF_I: �CONTIZA�TOR
NAML-: �� S'� C tI1�1C.vU LJ 4/l
�1DDPL-'SS: � �{Sd L4"<<�$(Ct'e � N CITI'
r�xorre: 7b3^-7�'(�-' ! ( 3�—
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ATL%7�ZIP �Y�Z
NAML: 1Ca..c�P^ t'Il�l.� JI
STATG LIC�NSG # L-XP DAT�
STATE BOND # � BXP DATE
ADDR�SS: aotC/D /r1Grl1 S'}' �� CITY r(�to��e� STATL/'YI� ZIPSS`/��,
PHONE %6'��iJr'{-eZl�/ fAX /li���lS�'�^7�0
GYS`1NGL� FAMILY
❑ NEW
DETAILED DESCRiPTION OF WORK
❑ TWO PAMILY ❑ TOWNHOUS�
�PLACEMENT
FEES ARE BASED ON $l 0.00 PER FIXTURE, �XCEPT WHEI2� NOTED. FIXTURES: (INDICATE TOTAL NUMBER•.OF EACH BELOW). MINIMUM FEE
$35.�0.
BATH SINK/LAV FLOORDRAINS SHOWER WATERPIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMNIING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
DISHWASHER LAUNDRY TRAY LWATER HEATLR ($35) FORlRRIGATION
— WATER METER OTHER
�tateSurch'�a�ga.. � $. ���� 5�.0.0���� �
(IVITNIMUM $40 00} Total = $ � O C�
TI-IIS IS �N APPLICATION POI: A PERMIT-NOT VAL1D UNTIL PROCL-'SSED
T hereby appl}� for a plumbing permit nnci I acl<nowledge th2t the infonnation above is complete and aeeurate; tl�at tl7e worlc will be in
conformance �vith the ordin�mces and codes o'the Ciry of T' •idley and with the v(innesota Const�•uction Cudes; that f understand this is
uot �i }�ermii� 7ut o�ly �u� applicatio�i for <i �erm and �vor' is not to start without � pennit on site; th�it Clie work will f.�e in accorciance
�,vith t�he �ipprovecl plan in tl ��e ur a� rlc �-vhic, re �es review <u�d anp�'oval of �piansQ.
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