P - 84366` Building
Inspections
763-572-3604
763-502-4977 FAX
DATE Jb— I�`- ��
SITE ADDRESS �. 585
THIS APPLICANT IS:
PROPERTY Nq
�I.,�Jl��IN�
�+ �I�EN'�'��., ���,�C1�'�'��N
C�TY ��' �+' ��+ � : .
EFFECTIV� 1-]-2012
YOURE-MAIL ADDRESS
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❑ OWNER C'tC`ONTRACTOR
Permit No.:
Received By' '
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OWNER% ADDRESS:��'}'� J CITY �f���'e•'I STAT��ZIP��'
TENANT pHONE: � �i 3"�,5� c� /��
CONTRACTOR NAME: fUetr CL 1u.n—b1 '
SUBMIT A COPY OF STATE LIC�NSE # P G �'�-I�� 3� EXP DATE �/ /
YOUR STATE
LICENS�, BOND AND STATE BOND # EXP DATE
CERTIFICATEOF ADDRESS:_�_OCZ°!� ��r1 S�"• ,�% CITY__��'; oI I�V STATE�ZIP�tf.3�
INSURANC� ^ G �{
PHONE 76 3'��J�' Y^ O� i-1 �7 FAX -%�3— 7"rJ `i'- cr� ( v�
PERMIT TYPE I �SINGLEFAMILY
TYrE oF woxx: I❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
LM£EPLACEMENT
� �e t.�.-+e r
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF'EACH BELOW). MINIMUM FEE
$35.50.
BATA SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHT[JB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
_ CLOTHES WASE�ER KITCHEN SINK WATER CLOSET T BACICFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER {$35) FOR IRRIGATION
_ WATERMETER _ OTI3ER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I aclrnowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fr' ley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and worlc ' not to art without a permit on site; that the worlc will be in accordance
with the approved plan in t f a w hich r i s revie and appr 1 of pl
SIGNA7URE OF APPLICANT P T E��!'�S �,p�7 DAT� �
APPROVAL IlVSP�CTORS SIGNATURE / a. , s ' naT�i�i 5i //�'i
Caty oi s�'�-aa�le�
�ui�ding �nspec�ions �e�ar*me�t'
6431 University Avenue NE, Fridley, MN 5�432
76�-�72-3604
FAX: 76�-�02-4977
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