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 ,
�