P - 48536�uilding
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�nspectians I���I��T�T 11 ��� ��������I'��I��
763-�72-3604 ���`� �. � ���'���
7h3-502-�977 F`�x EFFECTI\�E7-I-3010
DATE � YOUR E-MAIL ADDRESS
SITE ADDRESS -�C�� Y� Yl� �� ' �� �' ��
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
FFLQ�ERiY nT.AME: , , � - � l -
����� ADDRESS:�,ti�_ CITY I C-- �
�E"�IdAIVr�' PHONE: �-7_�, -�c�
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Permit Noa�l ly -(.l �'
Received By:
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ATE�ZIP
�'C1I'�T`Y'�ZAC'�'QT� NAME:
SUBMIT A COPY OF l f -
YOUR STATE STATE LICEI�TSE # ,� n. -��n oAA EXP DATE ��J 5�� /
LICENSE, BOND AND STATE BUN7� # �tii �iF�, 1'�Q(i �u' LtiT�
CERTIFICATE OF �D�SS 367o Dodd Rd� CITY STATE ZIP
�rsuxarrcE Pxor�� Eagan, MN 55123
� FAX
����.y. .r�� I'j�l SINGLE FAMILY ❑ i WO FAMILY ❑ TOWNHOUSE
TYP� OF �'�RF{: ❑ ��� �BEPLACFN�NT
DETAILED DESCRIPTION OF WORI� '`' r����-C��- ��,' `
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXT[TRES: (INDICATE TOTAL NUMBER OF EACH BELOW). MiNIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAI?�TS SHOWER WATER PIPING
BATHTUB GAS P1PING (NEED CITY LIC) SWIIvIIvffNG POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PP�EV. (�1�)
_ DISHWASHER _ LAUNDRY TRAY �WATER I�ATER (�35) FOR ffZRIGATION
WATER METER OTHER
Number of fixtures @ $10.00 x $10.00 — $
Number of fixtures a, $15.00 x$1�.00 $
''�� G'�
Number of fi�tures (a� $35,00 � x $35.00 — $ ,'�
State Suicharge $ 5.00 "
(1i'�I�'ili'��Jlp✓I ��0.001 Total $ �� ,� _
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII. PROCESSED
I hereby apply for a plumbin� permit and I acknowledge that-t� information above is complete and accurate; that the work wi11 be in
conformance with the ordinances and codes of the City of Fridley a�d vrith the Minnesota Construction Codes, that I understand this is
not a permit but only an application for a permit and work is not to s' wi hout a permit on site; that the work will be in accordance
with the approved plan in the case of ork which qu' view �nd p o al of plans,+� ''7� �
SIGNATURE OF APPLICANT (,' 'v � �-qTE -�' T �
.APPROVAL Iia'SPECTORS SIGNAT
PLE.^.SE NQTE: SEPA?2. PEP.^.�TS `<'�'tE It��',Q.,� D ':LD. G, ELECTF.IC� I;:.'.�'D Iv�',r'N-A_I�T?CAL WORK
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I�r�i��i�� �r�����tiar�� I�eg�r°t�er��
6431 University Avenue NE, Fridley, MN 55432
763-�72-3604
FAX: 763-502-4977