P - 48608�u�iding
�nspections
763-�72-3604
763-�02-�977 F�
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�FFECTiVE 7-1-2010
DATE � �� .�-07-' � J YO[JR E-MAIL ADDRESS '
SITE ADDRESS % �i 1 � i �.(e e ,�. � r�C � � �
THIS APPLICANT IS: ❑ OV✓NER JS�ONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMTi' A COPY OF
YOUR STATE
LICENSE, BOIVD AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE O� WORK:
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�ermit No
Rec iv�d B �
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Dat`�ex � �
0
ADDRESS: f�1 l � i e l. �.ti.e�l.. �L-�- t� r CITY F�t b l e- STATEH� ZIP �J �E3L
PHONE:'7%3-.Si� � S� S p
STATE LICENSE #
EXP DATE
STATE BOND # EXP DATE
ADDRESS: �..L"� D 1-_,l tiu... S� +^�+� CITY �ut�t dC �. c. STAT$�"' ZIP�.� V 3i,
PHONE � 63 °] �� � � Q °� FAX
�INGLE FAMILY
D NEW
❑ TWO FAMILY ❑ TOWNHOUSE
� REPLACEMENT
DETAILED DESCRII'TION OF WORK ,=n S�� t 1 VL��o I a- .-� �w b f w �,e �v.. l�C� F-� ►�✓
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV _FLOORDRAINS SiiOWER WATERPIPING
BATHTUB GAS PIPING (NEBD CITY LIC) SWID�IIvIING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATERCLOSET BACKFLOW PREV. ($15)
DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
WATER METER OTI-IER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the information 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 Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and work is not to start without a permit on site; that the work wil] be in accordance
with the approved plan in the case of all work which requires review and approval of plans.
SIGNATURE OF APPLICANT r � PRINT NAME (� i. r c. I�o D DATE � I' O� �-�" ��
APPROVAL INSPECTORS SIGNATiJRE
City of �ridley
�ualdang Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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RIUER CITV
Date' 2/24l2011 R�vision pate: �/24/�091 ExiStin� Constructic�n: Pr� � 994.
Site tnformation
Address �; 171 Rickard Ro�d Project #:
Address 2: l.ot: Block�
City: Fridley C�utlty: Subdivision:
ADpli�ation lnfarmation
�us�nsss N2r►'ye: MN Cont��kor Licer�se #:
Contact Rerson.
OfFic� Ph' �ax: Geil Ph:
Address 1:
Clt�� State� Zip Code:
Combustion Aoqli�nce
W�ter Haater; Natural �raft Inpui B7Us: 36,pOt1 Indeqend�ntly Vent�d
�urnace/8oiter: Direok Vent/Se�l�d �ornbustaon lnput BTUs: 6p,40q lridependently Vented
M�ke-tlp Ai�
NQ Make-Up Air Required by CodE
Cambustiort Afr
Minimum Cornbus#ion Air Requirements Met.
Applicant I�ame (prin#):_ ,,.,, - Signature/pate:
Code Ot#iclal (print); SignaturelDats:
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