P - 44621�u�lding
�nspections
763-572-3604
76�-�02-4977 FAX
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EFFECTI V� 7- I -2010
DATL l�- / SI d i 0 . YOUR E-MAIL ADDRESS
SITE ADDRESS C. 1.3 O �'-'i � i �. ( a S�� nJ C
THIS APPL]CANT IS: ❑ OW23ER �jaCONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMiT TYPE
�rYrE oF woRx:
Permit No '
Received By: � ' �`{�G
���� 0 2 201
rvr�rvin: i�-o n+a i ot �c t,. ��+ a� �
.SDDRESS: �. � 3U �"( C {� t r.1 Sc CITY FI@ (�o I� STATE HNZIP,
PHONE: i..� 1 - '1 � $ - ! ,i l I
STATE LICENSE #
EXP DATE
STATE BOND # EXP DATE
ADDRESS: �Sr1�1 O ��- (i-� L�k N� CITY F�+�l oC i STATE C'tY+� ZIP SS�(3L
PHONE �I b3 - � S � � � 1 �i � FAX
�INGLE FAMILY
❑ NEW
❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
DETAILED DESCRII'TION OF WORK T_ n s� o( � 12, 1��•--� �� E' W e��l �.�.. ���--� ""'
FEES ARE BASED ON $] 0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM F�E
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED QTY LIC) SWIMIvIING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATERCLOSET BACKFLOW PREV. ($15)
_ DISHWASHER `LAUNDRY TRAY �WATER HEATER ($35) FOR ITLRIGATION
_ WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the c e of all wo which requires review and approval of plans.p-�
SIGNATURE OF APPLICANT �� ni� ln� ;O PRINT NAME G��' � J � C 1r !� 1° DATE I r� I�' ��
APPROVAL INSPECTORS SIGNATURE-� _ _
City of Fa�idley
Buiiding Inspections lDepartment
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
_ ,.