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Fsom: 612 822 5408 Page: 313 Date: 7/22}2011 2:05:53 PM
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Building
Inspections
763-372-3604
7b3-502,4977 F,A.�
ne�rs '�Z.2..�1�
5tI'� AUDRESS _
77iiS APPLIGANT ISs
FROPERTY
OWl+IEit!
'I�NANT
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.. PLUMB�� p��tr�o.?L� 1
�+ SIDENTIAI� ��'�"X.xC.A,.�'Z(��' tteceived By:�
�ITY OF FRIDLEY n��°a,J�;
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YOUR
AnUhfiSS
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SUHMR A COPY (Tl� '".". . _ .
Y(}UR STAT6 STA'FE LIC�NS� # , %'� � IIA'TE i G
U'G`�NBE. BO2�'D AND 5rwr� sE?Nn � D� / �* DaTI� ��//1 /
cExr�lcaz�o� ��,�,ss- d ,�- c� /ll:���,xt.�.q srwre���!/L.
INSU,h�A.NC� PHONE- L�{�_�ZZr S`�'i � FAX �1`�Z � iGi! �i� ��
�"�lT T YPE ��GLE TAMtLY ❑ TWQ FA,HtJt.Y O TOWNNFiialiS�
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�EE3 AAE �A4�ri t)1N a1 U OQ P�R FDCTITIZE, EXGEP�F WfY[+.�i.� NG'�ED. FDCTC►RES: (II�TATCATB TOTRL 1VL?l+�IDEIt 4F ErkGR� B£LAWj. MiNiiNUM FE'�i
S75.S0.
_ BA'FH S�IKKJL�4V TLOftR Tl�A�tS SS{1WEit WATER MPII�ICi
_,,,,,13A7H't'UB G1iS �1NG (NEED G77'Y Lt{„ry ,_ SWtMI�ID;i�x P4�L � WhTER St3FiNEIt (T�3Sj
_t�ArHESw,4S�Tt —Ki'rGt�FaVSllvtc WnTEttCLUSL'T ,BACKFL;flwPPE�.(�is}
� T)tSHWA�'HFR _ �.AUI+IDRY'cRAY �WhTERHEAZLR (333j TtrR IItRICinTtON
,,,_, WATT�.k i�TCR. �,_, (f'I�R
',�IS IS AN AFPLtCATION TOR A PERMiT-NOT vALiD UNTii, PROC�SS�D
J hereUy apply foc a plumbing permit and Z acknowledge fhat the informstion abovc is complctc and accuratc; thst th� work will bc in
conformance wit�t the ordinances and codes of the City of �'ridley and wilh thn Minncsota Construction Cadcs; that I undrrstand tlus is
�pt a permit but ottly an spplication for a it d wotl: s not io sN.trl without a permit an sitc; that thc worlc will be in secord3nce
w�tFt the a{aproved pian in thc c �1i,7 � wuui u' review and appro�fplanq� j
S[CrNA1'URE OF APP[,iCANP �-- I'FLQ�rC NAME atLr �rc �(,�v�r-+� DATE
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City of �rYdle�
Bui�d'u�g �ns��ctions T)epartm�nt
6431 University Avenue N�, �'ridiey, MN 55432
763-572-36p4
�`AX: �63-�p2-4977
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