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Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ���° �Z
SIT'E ADDRESS __ tn?�7� �_
THIS APPLICANT IS:
PROPERTY NA
OWNER/ �
TENANT
��,gJ� � g�f�r Permit No.: LU I 1�•, (,�JU
��g��N'�'��� �PP�g��'�'��� xecei �ed ByA�
c��� o� ������ D������: -
EFFECTIVE 7-I-2010
E-MAII. ADDRESS
�lC�t �CC-Y 1�'�l '
❑ OWNER �ONTRACTOR
C�-L� �'� fin '�'�n irl
_ �, ,.r .
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CONTi2ACT'OR N,yME: r•h,,,.„„In.+ Dli �rr�hinn
SU$MIT A COPY OF STATE LICENSE # EXP DATE 12-� � Z—
YOUR STATE # 817i0-F'M
LICENSE, $OND AND STATE BOND # 651-365-1340 EXP DtITE
CERTIFICATE OF ,s,DDx�ss: 3670 Dodd Rd. ��Y STATE z�
INSURANCE PHONE agan, FAX
•,PERI�dIT.TYPE. .. . ,_�INGLE FAMII.Y
TYPE OF WORK:f ❑ rrEw
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
������ � ��� -
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT Wi�ERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACHBELOV�: MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CTTY LIC) SWIIvIIvIING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCI�N SINK � WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY _WATER HEATER ($35) FOR IRRIGATION
_ WATER METER OTHER
(MINIMiJ1VI $40.00) Total $ � �(� �;�
THIS �IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII. PROCESSED
I hereby apply for a plumbing permit�and I ac edge t,lf�the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the Ci of`Fri ley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an appiication for a permit and w k is ot to start without a permit on site; that the work will be in accordance
with the approved plan in the case of al rk which re i' ' w and approval.� lans.
SIGNATURE OF APPLICANT � c.S�t.WL�S � ��� ��
i of Fridley
Building spections Departanent
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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