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F3ui�ding
Inspections
7G3-572-3f0�
763-502-4977 FAX
DATE 7� "' �2
SiTE ADDRLSS ` (_(' �.
THIS APPL[CANF IS:
�'4�'1� �' R/
TENANT
PLUMBIN�
RESID�NTIAL APPLICATION
CITY OF FRIDLEy
❑ OlVNEFt
S[IBh�IT A COPY OF .�".� � • • `�`
YOUR STATE STA'i� LtCEI+iSE tf
LICENSE, BOKD AND STATE BOND #�
CERTIFICr�TEOF ADDRESS:I-�L�2
INSURANGE
PNONE 7 [0 3 -
PEEtMfT TYPE �STNGLE FAMILY
'1'YPE OF WORK: J o xew
OF Va'ORK
0
❑ TW� FAILIILY
� KEPL,�►CEMENT
Permit No.
r�et, u �a� T�7 � �Q 12
Da#e Rec'd:
-ciTS'� '�'�c,� S srard�}A-�re,
C',11 a C. �:�.. i� C.
EXP DATE _� Z .JI— �Z ^
�X P DATE _ I %,,"� �" L'.�
_C1TY "�,', � , STAT�/�% ZIE
_ f'AX 7 �C! ?J n s -'���5
d TOSVNHOUSE
�,�* �.
S-��- i.: Ga.t�' � G�- ft�; .,'�r-
FEFS ARE BASED ON S �0.00 PER Ffk"fURE, E:CCEPT WIIEIiL 1�T01'ED. FIJ{TC'RES: (R�lD�CATE l"OTAL �IUMBER OP EqCH BELAW).
_ 6.4TH SINK/LAV FLOOR DRAIAIS SfiQt\'ER R'ATER PIPiNG
_ BATHIITB � G.aS PIl'ING {`YEED CTC'Y LiG'� SIYIMMIi1G POOL i WqTER SOFTNER (S35)
� Ci.OT13E5 WASHER i K1TCiIEi�f 5iNK WATGR CCA5ET BACKFLOVJ PRES/_ (51'Sj
_ DISHWASHEit � LnUNdRY TRAY WATER HEA1'ER ('�35) FOR {RRIGATfpY
�WATER METER OTEIER
.�.�� .__.,
NtunberoffixturesQ$10.00 � x$2a.00=$ �%r {jl�
I�iumber of fizturres C,a �� 5.00 � x$1S.OQ -$
Number of fixtures �a $35.� _, x �35.0� _ $��
State Surcharge $ 5.0�
II�iIFtiiUM S35 lus snrchar e Tocal =$ yQ� (•�(�
THIS IS AN APPLICATiOh rOR A P6RAiiT-NOT VALID UIVTIL PROCESSED
I hereby apply for a ptumbing permit and I wledge rhat thc infarmation abo��e is com�slete and accarate; ;hat the work wiil be in
confonnance with the ardinances an e�,o the Ci ey and ith the Minneso-ta Constcuction Cades; that I underscand tRis is
not a permit but only aa ��licaHvn f a i not to �vithout a permit on site; that the work wiil be in accordance
wich the approved plan in case a h' re revicw d approv�J lan�s+-� �' 7
SIGN�TURE OF AP?LIC� PR NAME Ln'1.t •' f� S{'�-°'� DATE ! V'� .- �'� ...• �¢
APP120VAL IKSPECTn�tc crriv�Triu� _ . . _
City of Fridley
Buitding Inspections Department
643! University A�enue NE, Fridley, MN 55�32
763-572-36i)4
FAX: 7C3-502-4977