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YOUR STATL
I,ICENSE. BOND AND
CLRTIriCATE OP
1NSURANC�
PERMIT TYPE
TYPE OF WORK:
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PHONG:
STATL LIC�NSC # � �XP DATE
STAT� BOND fi 6XP DATE
ADDRCSS:���(� �Q..�YI J� � CITY �/�. d��ti S1'AT� mn ZIPr,.�-5`i3s�►
P�,oNE 7b3-7�'Y ai`�i F�h 7�3-�Sy a�o8'
�SINGL� FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO PAMILY ❑ TOWNHOUSL
C�IiEPLACEMSNT
FEES ARE BASED ON $l 0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER.OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV _FLOOR DRAINS SHOWER _ WATER PIPING
BATHTUB GAS PIPING (NEED CITY LTC) SWIMMING POOL _ WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACICFLOW PREV. ($I S)
DISHWASHER LAUNDRY TRAY �WATLR HEATLR ($35) FOR IRRIGATION
— WATER MET�R _ OTHER
�.STate Surcliar.ge:. `�, � � 5'.0.0 �
f1V1INIMi1M $40 00) Tota1= $ � � �4
TI3tS IS AN APPLICATION FOR A PCRMIT-NOT VALID UNTIL PROCLSSED
i I�ereby appl}� for a pluinbing permit anci � acicnowledge t�hat the information above is complete and acetu�ate; that the worl: will be in
conformance �vil�h tl�e ordinances �� co es � f tlie Ciry of Tridley and with Che Nlinnesotl Construction Codes; that I Linderstand this is
not a}�ermit �uC ouly �in applicaiion f a ��e mit ailcl wori: is ❑ot� Co sta�t wi�tliout a pennit ou site; that tl�e worl: will be �n aeco�ti�ince
�,vith the approved »lan in the c<ISe of al r which requires review ancl approvll o"r plans. �
SIGNATURLOI� �1PPL1C:An'IT PI�INTTJi1M� ��n�� �'
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