P - 44602.. �_ � � _ �_ � ,. � �, ,,, From. 763 572 8889 � Pa�e: 2(2 Date: 11 /5/2010 8:36:51 AM
Building
inspections
?63-572-3604
763-SQ2-4977
DATE _` � � r +�
SITE ADDREg$��
TfilS APPLlCANT iS:
OWNERI
TENAN'C
PLUMBING
RESIDENTIAL APPLICATION
FAx CITY OF FRIDLEY
EFFECTI V �. 7- t-20I0
� ;r "" � _ _ U12 E-MAlL ADT�RESS .r,-a-� tnvrr�� �
SUBMIT A COPY OF
YOUA STATE
LICENSE, BONII ATiD
CERTIFICATE pF
i1VSURANCE
PERMIT TYPE
O ObQ'N�R
C [TY
STATE LICEN$£ N
STATE HOi�D #
EJCP DATE
��
Permit No.:��' � �
Received 8y:� ' LL
��C����`��� 0 � .
� r
sr,
�SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
T�� oF wa�c: f❑ �Ew
Az�En nESC�rr�oN a� woiuc
�REPLACEMEM
FEES ARE BASED OIY 510.00 PER F(X'fURE, F.?CCEPT WHERE NL?TED. FTXTURES: (TNpICAT� TOTAL �UMSER OF EA H BR..aN�. MtNJ1�tUM FB$
S33.S0.
� BATH SINIKlLAV FLOQR DRAiNS ,! SHOWER
— BAT�B � GA5 PIPiNG (NEED C['fY LIC) SWIMMiNG POOL WATER PIPING
� CLO'IHES WAS3iER _ K17CHEN SiNiC — _ WATER SOFTNBR (S35)
�DISHWASHSR LAUhfDRY TRAY WATER ��S� � 8ACKFLQW PREY. �515)
--- �WATER HEATER (S35) • FOR IRRI� '. -•
WAT£R METE.R t)THER� � ^ .
, _ ,..kt .�?�euz'i? ,�r.;�m�_'�%x°:,��'.:'"uir�.�+";:;�...._..: �F:,i?r::'',� .::.��.. ...., , n..� ,�. °' . .._,. . ���. . x ... . , .. . . _ � � _ -�-•
--- . _ ......... ................::
TH4S IS AN qPPLICA770N FOR A PE'RMi'C•NOT VAL1p UNT]L PROCESSED
I hereby apply for a plumbing pernvt and I acicnowledge that the infarnnation above is complete and accurate; that the woric will be in
conformance with the ordinances and codes of the Ciry of Fridley and with the Minoesota Construction Codes; that I understand this is
not e permit but only an ' ation for permit and work is not to start w' out a permit on site; that the work will in accordance
with the approved plan in t ich requires review and a al plans_ � 1
SIGNATURE OF APPLICANT PR1NT NAME' ��^�Z.E 1 ��
APPRQVAL R�iSPEC'f�RS S1G TClRE
City of Fridley
Building Inspect�ons Department
6431 EJniversity Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977