P - 48603/,
�uilding
�nspections
763-572-3604
763-502-4977 FAX
DAT'E �� � ,
SITE ADDRESS _
THIS APPLICANT IS
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�.��L���T 11 ��:.� ��'�� � ���II'����T
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EFFECTIVE 7-1-2010
YOUR E-MAIL ADDRESS
❑ OWNER ;�ONTRACTOR
PRQ�ER'£Y n�A�vt�:1��jP,1 �Z1,c,b�►
������ ADDRESS: _�G�Y� � CITY�
TEIV.4NT PHONE:a �" �� ( � L�
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Peimit No.:'
Received B : ` � �
Date ���� �
ST
�C3I'�T�R.4C�'Q�I�' NAME: �il'�3f7d�IQYI ��L113ii]li"1t7
SUBMIT A COPY OF STATE LICENSE � � C�% i��-�`M EXP DATE �%�Z
YOU!; SZ_ATE
LICENSE, BOND AND STATE B�NU � 651-�6�-134� E� ;,A; E
CERTIFICATE OF �DRESS: ` � � CITY STATE ZIP
INSURANCE PHONE �` ' F�
PEFZ�IT T`�PE I��GLE FAMII.Y ❑ TWO FAMILY ❑ TOV✓NHOUSE
TYPE O� WORK: � �W ���•PLACENIENT
DETAILED DESCRIPTTON OF WORK I
FEES ARE BASED ON $10.00 PER FUYTURE, E3;CEPT WHERE NOTED. FLXT[JRES: (INDICATE TOTAL NUI��ER OF EACH BELOW). IvIINIML1M FEE
$35.50.
BATH SIlVK/I,AV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) � SR'IMNIING POOL WATER SOFTNER ($35)
CLO'I'HES WASHER ^ KITCHEN SINK � WATER CLOSET BACKFLOW PP�EV. ($1�)
' DISHWASHER `LAUNDRY TRAY WATER HEATER (�3�) FOR ff.RIGATION
� WATER METER OTHER
Number of fixtures @ $10.00 x $10.00 — $
Number of fiatures a, $15.00 , a$1�.00 $
Number of fixtures (�a, $35.00 : x $3�.00 — $
State Surcharge $ 5.00
(1V�NE1V'�Ult'� $40.00) Total — $ �t' • �l�
THIS IS AN APPLIC.4TION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbin� permit and I acl:nowled�e that the infoimation above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the I�Qinnesota Construction Codes, that I understand this is
not a pennit but only an applicat o or a pei hit and ork is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case o �v tc � a d appro � f plans. 1 r
SIGNATURE OF APPLICANT _ � _ 7vIE � DATE J�`" J�� 2�
APPROV.AL 1NSPECTORS SIGNAT
PLEASE I�'OTE: SEPARA _ RE UIRED OR BUILDING, ELECTRICAL AND NIECHANICAL WORK
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�r�iflc�lir�g ���g��trdr�s �e�a�-�a���g
6431 University Avenue NE, Fridley, MN �5432
763-572-3604
FAX: 763-502-4977
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