P - 48235�L1ilClillg ��;������ Perniit No.: �{1� '���
�nspections ����1�T � ��, ������� �'��I� xe�„��ed By:
763-�72-3604 ���'� ��' ������ ����e����1�
763-502-4977 FAX cFFECTivE�-i-zo>> �
DATE � oZ "�' 3' `� YOUP. L--MAIL ADDRESS
SITE ADDRESS �% 3� 1'� l S S ( S S � � , �, j �y� � � rJ 5 S 4 3 i.
THIS APPLICANT IS: ❑ OWNE �ONTT�ACTOR
PROPEYiT�' . NatvtE: 4-� v2. t ���. iL Oh r� z� o t dc o..�
OWNER/ ADDI2�SS: �3a i"( l 35 tS .1 �,Q (� t ,5\ �v� CITY r' (2-� �p� STATE � ZIP � r�`� �
'��NANT '� �
PxoNE: ���., S 7 i� 2i8 -7
CONTRACTOR NAME: ,, L c,-
SUBMIT A COPY OF
YOUR STATE STATE LICENS� # BXP DATE
LICENSE. BOND AND STATL BOND # E�P DATE
CERTIFICATE OF ADDRESS: kd�t b ��-.. c�h - N� CITY Fl2t �4C«. STATEMa Zip b S ��
INSURANCE pHONE % b3 �'� S� - a� Q g rax
PERMTT TYPE �SINGLE FAMILY
TYPE OF WORK: �❑ rrEw
❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
DETAILED DESCRIPTION OF W ORK I✓1�yk ►-� l �r ,b� d L��t ��� L�.%A � w �� �.�--� �
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WI-IERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM PEE
$35.50.
BATH SINK/I,AV FLOORDRAINS SHOWER WATEREIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER HITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
_ WATER V[ETER _ OTI�R
�Furaber af fzxturc
�tumber of fixture
�,.�,c,
5 00
�State,Sur�l�arge ��, _. : �_ , � _
(11%TIlYIMT]M $40:00) Tota1= $ �-c�: h�+
TH15 IS AN APPLIC.ITION POR A PERMIT-NOT VALID UNTIL PROC�SSLD
( hereby apply for a plumbing permit and I acicnowledge that the information above is complete and accurate; that the worl< will be in
conformance with the ordinances and codes of the Ciry of Fridley and with the Minnesota Coustruction Codes; tllat I �mderstand this is
not a permit but only an application for a permiY and worlc is not to start with9 ut a permit on site; that the worl< wi11 be in accordance
with the approved plan in th case of al] w rl< which requires review d appr��l of plans
' .%��1.� r v DATE i�.- - l
SIGNATURE OP APPLIC.�NT i�. T NA
APd'TiO Vh L SNSTE C; ORS SIGNA'3'UR� ������
PLEASE Nt�T'E: SEP,4R��T� PERMI S;�RE : �U1R�D FOR B ILDfNG. EL�CTRIC_AL ,�i�D' V[ECHANT .=1L W RK'
�L3$�'>' �I[ 1� i 1Cl�e�'
�Yll�C9fli1� �1H1SB38CfiIl0%15 ��37�&'*Il11e�Y
64�1 liniversiry Avenue NL, �'ridle��. tiII'�I �����
75�-�;�-�604
�'A �: 763-�0�--�97�