P - 41739�uilding ��,�TIl����
�nspections �S��IlT�'�� ����������1�
763-572-3604 ���'� ��' �'�����
76J-5�2-�977 F�i EFFECTIVE 1-1-2011
DATE __/lJ � ��=
-T o
SITE ADDRESS ��
THIS APPLICANT I5:
PROPERTY
OWNERf
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
_ PERMTl' TYPE
TYPE OF WORK:
YOUR E-MAIL ADDRESS
❑ OWNER ,�@C�NTRACTOR
NAME:�/� �_7 yU^�-A 5 /
ADDR�SS: �Q SJ(���./C� CITY f��l� r�
PHONE:
NA1vIF� /./I�/ ��C _. '/ V l�lv.« 6��.,
STATE LICENSE #_
STATE BOND #
ADDRESS:�-�
PHONE ?�7
C�S�IGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
Y"�.y�`'a J �`' �si
�y
❑ TWO FAMILY
PLACEMENT
CITY�
FAX
❑ TOWNHOUSE
Permit No.E
Received
�XP DATE
EXP DATE
1�"�- ` `-. a � : ,
TE ZIP,
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACIi BE . MINIMUM FEE
$35.50.
BATH SINK/LAV FLOORDRAINS SHOWER WATEREIPING
BATHTUB GAS PIl'ING (NEED CITY LIC) ^ SWIr�IIvIII4G POOL WATERSOFINER ($35)
CLOTF�S WASHER �KITCHEN SINK WATERCLOSET $ACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY _WATETi HEATER ($35) FOR IlZRIGATION
_ WATER METER _ OTI�R
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROC�SSED
I hereby apply for a plumbing permit and I acicnowledge that the informafion above is complete and accurate; that the worlc will be in
conformance with the ordinances and codes of the Ciry of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit d worlc is not to start without a permit on site; that the work wili be in accordance
with the approved plan in the case of al] wor ch requires review and approval of plans. /L /
SIGNATUR� OP APPLICANT AM � DATE��/ �-'< �
t1PPROVAL INSl'EC'�'ORS SIGNA'Y'UR� ' DATL
PTRACFNn'T'F'� CFPARATF`'PFR TCARFRFr'1TTTRFT�Ff1RR1Tii.T�TNC'T'RT,F.C'T'RTC`A1`:'Ai�TT)M�C".HA1ViC'At:WORt�
�'�� m� �� �c��e�
�uilcding �nspe�iflons �epa�-�a�e�i
6�� 1 University Avenue NE, �'ridley, NLN �54��
763-572-360�-
FA �: 76�-502-�977