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P - 44623�riSp�Ct10iIS 763-572-3604 763-�02-4977 FAX � ; �: ; . � �; , , ,� �• . fi �„ � ���� �� ������ �FFECTN� 7-] -2010 DATE J l� I�-"' -(� YOLTR E-MAIL ADDRESS SITE ADDRESS f� (� 3 C, �` i�c n� t_ �� N� � lL-1 � � Y+ THIS APPLICANT IS: ❑ OWNER �CONTRACTOR PROPERTY OWNER/ TENANT CONTRACTOR SUBMIT A COPY OF YOURSTATE LICENSE, BOND AND CERTIFICATE OF INSURANCE PERMTT TYPE TYPE OF WORK: ?'ermit No.: Received By: Date���:� NAME: '2 U ✓1 `3. I (yL. � (` (n Q.�1 Gt C � ADDRESS: � 63�1 t- 4�ihl�, 5E 1-'t CITY__�,Q, r� � STATDMr� ZIP bS���s1- PHONE: (v S �'- �?J � ( S � ( NAME: i2 �.. . v �'i �t, ,� ln Lv�c t( � 6b--� -- -- STATE LICENSE # �— EXP DATE STATE BOND # EXP DATE ADDRESS: /� �J � �'� " S� tN �` CITY C, �,2, �,o � STATE t'? � ZIP S S�i3 L PHONE � < 3 � S �F a ( �t �1 FAX `�SINGLE FAMILY Q NEW ❑ TWO FAMILY ❑ TOWNHOUSE '�B REPLACEMENT __ __ _ DETAILED DESCRIPTION OF WORK �ns-� q(\ R,�� Ia-e�e-«,,.i.-� ��.p���, jd �� G✓" FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WI-TERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE $35.50. BATH SINK/LAV FLOORDRAINS SHOWER BATHTUB GAS PIPING (NBED CITY LIC) SWIMIvIING POOL CLOTf�S WASHER KITCHEN SINK WATER CLOSET _ DISI3WASHER _ LAUNDRY TRAY �WATER HEATER ($35) _ WATER METER THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED WATER•PIPING WATER SOFTNER ($35) BACKFLOW PREV. ($15) FOR IRRIGATION OTI-IER I hereby apply for a ptumbing permiY 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 case of all work which requires review and approvanl of plac�s. SIGNATURE OF APPLICANT C�-� �o �-L r,o � 1 PRINT NAME `' In r� J 1Q-"O �)_DAT� /(-{ b-� (� APPROVAL INSPECTORS SIGNATURE —�T�-�iM�r-� _ _ Ciiy of �'ridley �ualding Inspeetions Depag-tment 6431 University Avenue NE, Fridley, MN 554�2 763-572-3604 FAX: 763-502-4977 O� ��� a � b �b • � �U , �