P - 39348Building
Inspections
763-572-360�4
763-502-4977 FAX
QATE 7� /
SITI: AffnRFSS _�
THlS APPLICANT IS:
OW1VER/
TEVANT
CONTRACTOR
SUQMIT A C�I'Y OP
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OP
IN5URANCE
PERMIT TYPE
TYPE OF WORK:
From: 763 262 1914 Page: 2/2 Date: 9/6l2011 11:12:15 AM
PLUIVIBING
RESIDENTIA� APPLICATIUI�I
❑ OWNER
NAME: ,. � �
ADDRESS:
CITY OF FRIDLEY
EFFECTiVE i-1-2011
Permit N
Received By:v� �,!��
���:� �' 0� � 2 �
YOUR E-MAIL ADDRESS �� ��'`1 a�'"�'rSa h- pl u w+�rny . C'o r-� V
C /A/�/ I►�� � .
�,EONTRACTOR
Y V �Vl �
C1TY
ATF %IP
xnME: ia'+"rt'�san t,uwtitxn Prhoa��rn Ll,c
STATC L[CENSE � y.� �i ��K Dbsv8cl� f'M S�� GXP DATE Ia 31 a 1 Y
srn�re soNn a J�Cl4 0�� 3�j °v `� Face oa•r� / 3��✓
ADDRESS: I�`? %o� E��r W�Y CITY i���^� ��fi'�Y STATE I�^! ZIPy��
PHdNE FAX
�SINGLL CAMILY
❑'NEW
DETATLED DESCRIPTiON OF �`'�RK
L]' TVVO PAMILY Cl TOWNHOUSE
�REPLACEMEN'f
FCES ARF. BASLD ON 310.00 PCR [•IXTURB, GXCEPT WWERE YOTED. FIXTURES: (1NDiCATE TOTAL NUMBER OF EACH [3ELOUV). MINTMUM FEE
�5.50.
BATt1 SINK/F.At' FLOOR DRA1N3 SHOWER WA7ER Pll'ING
�[iATH7'UB GAS PIPING (NEED CfTY L1C} SWIMM1rG I'001. WATER SOFTNE[t (535)
CLOTIiES WASI•IER TKITCHEN 5INK WATERCL4SET �B�CKFLOW PREV. ($l�)
� DtSHti%ASMF.R � LAiJ�IQRY TRAY WATER MEATEIt (E35) � FOR IttR[GA770N
� � WA"fER METGR DC QTHER mis�utf" i�a�VyC-
Number of fixtwes (ct� $ l'O.Ot? � x $1 fl.00 = $ � � `a`�
Ntur�er vf fixtures Q$T5.OU x$15:00 =$
1rEumber tsf fixitares Q$3i.0i3 x$35.00 =$
State S�archarg�
$ 5.�
M�Nin�tJn��au.uu -i•�=� �•--
T[{IS IS r4N APPLICATIOV FOR A P�RM IT-NU'l' VALiD l.Nf1L PR�3CESSED
I heceby apply for a plumbing perrnit ancl t acknpwledge that the inforn�aiivn abo�e is camalete and acc�rate; that the work wiil be in
confomta�ce witb the ord�nances sttd codes of the City of Fridley arid with the Mirtttesota Constru�tioa� Codes; that 1 understan� this is
not a pertnit b�t oniy an app�iaatian for a permit work is nat to start without a perniit csn site; that she work will be in ac�cordarece
with the appro�ed plan in the e hich equires review and approv ! of ans. F /f
SIG3VATURE OF APPLI�ANT PRII�IT NAM� �Lt+"� /'J�Q�7l DA7"� itf f I r
City af Frid�ey
Suilding inspections Department
6431 Unive�ity Avenue NE, Fridley; MN �543?
763-572-3644
FA�: 763-502-4977