P - 48208�uilding
Inspectians
763-j72-3604
763-502-4977 F�4X
DATE , ��
SITE ADDRESS
THIS APPLICANT I5:
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EFFECTIVE 7-1-2010
❑ OWi�TER
�R�PER'I'Y Naiv�:
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PHONE: '
YOUR E-NL? IL ADDRESS
Permit No.:
Receiv_ed_B�:
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ATE /'l���
C'OIVTRt$,C�PQ�&Z �'AME:
SUBMIT A COPY OF STATE LICENSE # �177f1_PM ~ EXP DATE
YOUR STATE #
LICENSE, BOND AND STATE BONll � �5� -'�65-1340 E7.� U.�TL
CERTIFICATE OF ,�D�ss: �670 Dodd Rd. cITY STATE zIP
�rsvx.�rrcE Pxo� Eagan, M�1 55
FAX
P��IIT T�'PE I��GLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF' WORK: ❑ �W �PLACEMENT
DETAILED DESCRIPTION OF WORK _��,� / �,Q�.��Y ((�'P�SPI�-C-C!l�t�.�►'�,
FEES ARE BASED ON $10.00 PER FIXT'fJRE, E3:CEPT Wl-IEP.E NOTED. FIXTURES: (INDICATE TOTAL NiJMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/I.AV FLOOK DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) � SV��IIvIIvffNG POOL WATER SOFINER ($35)
CLOTHES WASHER HITCHEN SINK i WATER CLOSET BACKFLOW PfiEV. ($1>)
� DISHWASHER LALTi�TDRY TRAY �WATER HEATER (�35) FOR IRRIGATION
WATER METER OTHER
Number oi iUiuces C aiO.Ov _ x$10.v0 — n
Number of fiztures (a�, $15.00 _ x $15.00 = $
2 6p
Number of fixtures �a, $35.00 � x$35.00 $ J��
State Surcharge $ 5.00
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(1Vfi�1�TY1QTiTI1WI $40.001 Total $ -`/ �. ;
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII. PROCESSED
I hereby apply for a plumbing permit and I acknowled�e 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 pennit but only an application far ermit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case of all wo c which quires review and approval of plans.
SIGNATURE OF APPLICANT P T NAME DATE
APPROVAL II�'SPECTORS SIGNATURE
PLEASE NOTE: SEPA E REOUIRF.D FOR BLJ?LDI?�TG, ELECTF'.ICAi; Ai�]D A�]ECi�Al�i1CA1, WORK
���'j' 0� �L'tC�IC',�'
�r�rid��b ����ee�r��s Ii��p�r�me��
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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