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P - 48416�L1X�C�XTlg xx�spect�ons 763-572-3604 763-502-4977 FAX From: 6514235677 Page: 1/1 Date: 2/22/2012 4:23:37 PM �����Y�� �E��DE�1T'�'�.�.4.L .�PP��C.A,'�'�Q�Y CITY O� k`��L,E'Y EFFECTIVE 1-1-2012 k�erm�t �To. �j��u� ,�'�i(� ;?�.,1^ Rece�ved By: ��� ����°��` _ � � � DA�� 2j�1�'��1�^ YOURE-MAILADDRESS �u�ia.f�uv+�baS"�q�-�tY1C�t�t,awl S�'E AFJ]?�E55 C? � 5�'- i\} • i� • J '�ZS AP��,xC�1�1't' 1LS`: ❑ �WNER CdNTRACTOR PROPERTY ���._ OWNEI�i! ADpRESS TENEINT coNrx�►cTaR susM[�r � co�x o� '�'�U�L S�A,"�� �.xC�iS�, ��NA ANU CERTIFICATE OF INSURANC� ��RMl7" `�'X�� TX�'� O� WO�ttf: l��" > r .-. M��,w�.tS sr,are '�N��� s��- S�'A4�� x,ZC�NS� #i ��- la �'.��+�Q� `� E3CP DATE � 2'3 l"- �•Q l� S�'t#� �D�►a # �hai � 4'�u �a.�� S �.XP DATE 1�^."' � 1� 2..� 1 x.- a�n�s s: 36�3 ! 55 �' .S�F= W. ,. ciTX Ros�e.�a �s w►•F- s�,�� M Nz�S� �(� S pt�o�t� (���1 32� � �� 69 �,ax i�S 1 `f z3 �` �� � �- � �� SI�VG�.� kA�Z�.X Q NEW ❑ TWO kANxxl.a CJ TOWNHC�TJSE �EPLACEMENT DETAIL�D DESCRIPTIOTV OF WO,i2i{ T�.t►��C,e, �c��-e�r L��o�t+� �'�£S ,f4�£ �AS,61j 01V $10.00 k'HA FI3CCURE, E}{CEPT WF3ERE NOTEA, FI?�T[JIt£$; (INDICATE TOTAL NUMBEA OF E[aCil SHLOW). MINIMCTM FEE �3s.sa. �A�i SINiC/LAV MLUdIL UxAINS SI-xOW�K HATHTUB GAS PIFING (NEED CITY LIC} SWiMMING POOL C�.p'fki�S wAS���t KI�C��N S�N�C wA��� CI.OSET _� DISHWA3HF�FL _ LACiNDRY TRAY �WATER HEqx��L ($35) WATER MEXE� . � � , , :z ,, ,: � ,;�: � ` „ , , , . , ,... :� , �::;: �S xS A�I A�,ZCA�'�O�T k'O�t A P�KN�IT-�VOZ VAd,IT? UNTIL AAdCE5SET1 WATER P1P1NG WATER SOFTt+1Eit ($35} �BACKFLOW PREV. ($15) �Ok� I�GA�'F�N _ oz�� x hereby ap��y for a plumbing �ermit and 1 acknowledge tfaat the infqrrr�ation above is complete and accurate; that the work will be sn confortnanee with the ordinanees and codes pf ti�e City of Fridley and with th� Minnesota Construction C;odes; that I understand this is noZ a petrnit bu1 orlly an application far a permit �nd , ork is rtot to start without a pezznit on site; that fk�e wazk wia� be �z� accordance witEz tb,e appzdved plan in �c3�e case of ail work h� uires xeview aad approval of plans. , SIG�A�tEOFAPPi.ICANT �--'�-�_� _._,�, _. 'VTNAMb_�'I�Y�d ,{l[�,S DATE �. ���^'�¢'[2-. ---._...... — - -.. _.. APPitO'VA%. IN$P�CTORS SZG�TA"['Ux2� - DATE�'> >— I - �l� O� �Xld��� �ux�d�x�g ��spect�o�:s Ae�aaz�tm�ni 6431 LT�ive�sity Avenue NE, Fridley, �i 55432 763-572-3b04 FAX: 763-502-4977