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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