P - 44558Building P'LU�'IBING
Inspections ���DEI'�iTIAL APPLICATIQ�
763-572-3604 ' �'IT� �F' �RI�L��
7b3-502-4977 FAX ,:�:.FECr,�,.�.,-,-��,,
DATE YCJI'R E-A�?A[L ADDRES4 wnelsonCa�larsor
siTE�u.,DaESS 4042 Main St NE
THIS AFPLiCANT IS�
OWNEW
TENANT
SUI3M1'1' A COPY OP
YOIJR 5'I'AT"[:
LICI:NSI;. I30Nb ANI)
cF:x�r�rrc.a•rE or•
INSURAAICF:
P�RMtT TYPE
� t)W�'ER SICONTRACTUR
Permil No.:
Received By:
Date Rec-d:
N �mE: Amande Dahn
n�nRESS: 4042 Main St NE c��-�� Fridiev sT.�TEMNz►P 55421
PHONE:
NAME: La�'�'.s0T1 I''IUR1DIIlQ, II'1C.
___..... .
STATE LICENSE q 58757 3341 PM Ex�r onrE 12/31/11
STATE B()ND # EXP DATE
_ �.__� __._.. �.._. �.� __.� _ � W ,...� �...
,AnQ�ss 3095 162nd l.ane NW �c�T� Andover s�.��fE_MN z,r 55304
PHC)IYE 763-427-%USO FAX 763-427-9448
� SINGLE FAM[Ll` ❑ 1'4V0 FAAi1LY ❑ `l�()tk'NHC}USE
TYPE 4F WQRK: °�' Ew Q[ REPLACEN�ENT
� _______ ____ _ ____ _ _ ____.�,�_.__.___.__..__........._ _.. _~-�_�.. __ -(-7- � ,_ � �,_.�; / �"""""""""""%��"
DETAILED DESGRIPTI{)N OF WU[iK FQ�l�'� _.�__�GAn dJ►"1� 1 �:��J�'��l - y"'���
FEES ARE BA.SED (7?�I 510.00 PER FIXTLIRE. EXCEPT WHERE NC)TEC1. FiXI'[JRES: IIrDICATE TOTAL NUMBEit OF EACH BELOW) MINIMIJM FEE
$��.�0.
� BATH SINK(I.AV FLOOR DRAINS � SHOWER VGATER P[PING
= BAT}iT[JB _GAS F[PING (NFED CITY LIC) SWIMMT13Ci PO(?L. V1'ATER SUF'fNER ($351
CLOTHES 1V.4SHF.R KITCHET4 SINK � WATER CLOSEf � BACKFLOW PREV. (SIS�
D[SHWASHER LAUNDRlt TRAY W"ATER HEATER ($3� 1 FOR IRRIGA77(7I�1
� � WATER METER OTHER
TI[IS IS AN APPLICATION F'OR A PE•ItMIT-IvUT VALID iiNTIL PROCTSS�D
I hereby appEy for a pEumbing permit and 1 acknowledge that the infor�nation above is coinplete and accw�ate; that the wo��C wilf be in
conformance with the ordinances and codes the City of FridEey and w�ith the Minnesota Construction Codes� that 1 understand this is
nat a pemiit but only an applica ' for a pe and ork is not to start without a pennit on site; that the work will be in accordance
with the approved plan in the o 1 s review and approv 1 of plans.
� � PRfN'T NAME ti I � I/�I`.75�1"� DATE � _
SIGNATIJRE OF APPLICANT ' v
APPROVAL INSPECTORS SI _ liRE , ' _.... __ DATG
Citv of Fridley
Buitding Inspections Department
643I Lniversitti� Avenue NE, Fridley, MN 55�32
753-572�360�
F�1X: 763-502-�977