P - 41198Building
Inspections �ZESjD
763-572-3604 r
763-502-4977 FAX
DATE �/ � � t'J ' �l
SITE ADDRESS {� 7`j % i�' i} C� r� o��
�is n�r�,icnrrr is: n owrv�z �
PROPERTY Np�: �QC�
OWi�ERI ,�pRESS: CC� `7
TENANT _,.�_.��._-,.
CONTRACTOR NAME: i t� �'�
SUBMT£ A COPY OF STATE LICEI�SE #�
YOUR STATE
LiCENSE, BO1�tII AI�iB STATE BOAti) #�7
CERTIFICATE OF ADDRESS: 7 �/G'1
tivsu�rtcE PxorrE 7[� �- 5
PERNIIT TYPE I �S�GLE FAMILY
TYPE OF WORK: I II x�w
DETAILED DESCI�IPTION OF V✓ORK
FEES ARE BASEd ON $10.00 PER FI7C7'[JRE, EXCEPT WH
$35.50.
BATH SII�tKfLAV FLOOR DRAII�lS
Bp�� GAS PIPING (NF
CLOTiIES WASHER KTI'CHEN SINK
DISHWAS(�R _ LA[JNDRY TRA
Nuinberoffixtures�a $10.0(} x.$10_QQ'=$�_
Number of fixtnres cQ $15_OU x$i5.0U =$_
Number offixtur� Q$35_UO x$35.00'= S
State Surcharge $—
[n�[ttvrMiTM Sd0.00! Totai = $_
THIS IS AN
' 1� i
APPLICATION
QF FRIDLEY
FFFCTIVE t-1-2011
E-MAIL ADDRESS
t� M
TWO FAMILY
T�REPLACEMENT
Permit No.:
Received By: � i�'�
��Re�'��' 16 20
STA1°E� 1� ZiP�.3
�crDA'rE td��iiac�/�
EXP DATE �� I�i f{.>2 O It
CITY - r,� 1�2 � STATE M aJ ZIP�.�3�
_ Fa� �'b 3- 7 lo- 9 S:�
� TOWNFIOtJSB
�
Hp7'Ep, FI}CTtJRES: (INDICATE TOTAL NUMBER OF EAGH BELOI�. MINIMUM FEE
SHOWER
LIC) SWiMNIII3G POOL
� WATER CLOSET
WATER HEATER ($35)
� 1�VATER Iv�"I'ER
�5� cc �
�
3;
5.00 ;,
a`
� ��_ � b
FOR A PEftMIT-AIOT VALID UNTIL PROCESSED
WATER PIPING
L WA'1'ER SOF'CNER (T35)
BACKFLOW PREV. ($i�
� FOR IRRIGATIOTi
OTHER
I hereby apply for a plumbing perniit and I ackno �edge that the information above is complete and accurate; that tt►e wark will be in
conformance with the ordinances and codes of th ' of Fridl and with the Minnesota Construction Codes; that I understand lnis is
not a permit twt only an applic�tion for a petmit d w rk is t ta stait witfiout a permit on site; that the work will be in accordance
with the approved ptan in th ��of all work whi requ view and approv� of plan . _ _, �
SIGNANRE OF APPLICANT �'� u=�-�- � P���ME � �`1 � "�' ��°-� ��S DATE
.a i�ATE J
ity of Fridley
Buil g Inspections Department
b431 Uni rsity Avenue NE, Fridley, MN 55432
763-572-3fiO4
FAX: 763-502-4977