P - 48610.. � � `� ,` �. � �. ., , From: 763 572 8889 � Pa�e: 1!1 y � Date: 3b16l2012 9:58:04 AM � � � �
Build.ing PLUMBING Permit No..��
Inspections RESIDENTIAL APPLICATION Received By�
7b3-572=4977 FAX CITY OF FRIDLEY Dat��:_
763-502 E�cnvE 1 i
DATE -� � � �'
SITE ADDRES S 2
THIS APPLICANT IS:
PROPERTY
OWNERI
TENANT
2-
4% l vc
❑ aWNER
x.�.
ADDRESyS:�
PHONE: _!_�i[ ��
YOUR E-MAIL ADDRESS
'�(,�`ONTRACTQR
�
CITY
��
CON'C'RACTOR NAME; ��'ifl..t i�UP,�C.iLq�C,_JJI L6•�— b!"+T
SUBMIT A COPY OF STATE LICEN5E #i PG Qp /� t/"� EXP DATE'y � !�
YOi3R STA7E
LICENSE, BOND AND STATE BONU # D� F✓�JL EXP DATE
CERTIFICATE OF ApDRESS: �'.'� ?. � M e+i S'fi _CITY%�f► o Y� STATE�i�ZIP�53 �
INSURANCE PHONE �iLO � " �7a^pS�`0 FAX iI1rS - '�'.�i u`��'�ii °1
PERMIT TYPE �s�C`� �'��LY d TWO FAMILY ❑ TOWNHdUSE
TYPE OF WaRK: a NEw ��-.ACEn�Nr
DETAILED DESCRII'TION OF WC)RK � C�.c.� C',�."G.; �l- hnuse. Sl �]o�.�t. `+--5�'""� ab'b
FEES ARE BASED ON $10.06 PER FIXTURE, EJiCEPT WHERE NOTEQ.
$35.50.
BATH SiNK/LAV FLO�R DRAINS
— gp�[� GA5 PIP[r]G (NEED CITY LIC;
CLOTHES WASHER KTi'CHEN SINK
� D1SHWr1SHER _ LAUNDRY TRAY
FIXTURES, {INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
_ SHOWER
SWIMMING POQL
� WATER CLQSEC
�WA'CER HEA'I'ER ($35)
WATER METER
WATER PIPING
WATER SOFCNEIZ (335)
BACKFLOW PREV. ($15}
! FOR 3RRIGATION
OTHER
THIS IS f�N APPLSCATION FOR A PERM7T-NOT VALID UNTIL PAOCESSED
I hereby apply for a pfumbing permit and I''a�knowle��ge that the information above is complete and accurate; that the woric will be in
conformance with the ordinances and cades o�the Cit}� of Fridley arid with the Minnesota Constnzction Cotles; that I iu�derstand this is
not a permit but only an applicatian for a permi and ` ork is not to start whhout a permit on site; that the work will be in accordance
with the approved plan in tt�case of work h r uires review and a rC}val of lan�''' + ,`�,�a
SiQNA7'(JREOFAPPL[CANT�[ � PRINTNA_� /�J�A�a� r��'2S1MM��DATE �
APPROVAL INSPECFORS SIGVATURE
City of Fridley
--�uilding Inspections Department
6431 University Avenue NE, Fridley, 1VIN 55432
7b3-572-3bb4
FAX: 763-502-4977
�'i Z.