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P - 44995Building p�.,�J����� Inspections ��5����T���� ��p��������T 763-572-3604 ���,� ��, ������ 76J-JQ2-49 / 7 F��i EFFECTNE 1-1-2011 DATE �� C� SITE ADDRESS _ THIS APPLICANT IS PROPERTY OWNER/ TENANT OWT�IER NAME: I U r 4• ADDRESS: � PHONE: � ' �p � rl YOUR E-MA[L ADDRESS CITY Permit No.: a� Received By:�/ �����R 1 ATE CONTRACTOR NAME:�U V� �T'I ���� %k9 SUBMIT A COPY OF STATE LICENSE # EXP DATE YOUR STATE LICENSE, BOND AND STATE BON # EXP DATE CERTIFICATE OF ADDRESS: C CITY STAT�IP J� 2 INSURANCE pHONE __ �'_ �'� ZL� ___ FAX aJ' PERMTT TYPE TYrE oF wo�: I� NEW FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE DETAILED DESCRIPTION OF WORK �PLACEMENT FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE $35.50. BATHSINK/LAV _FLOORDRAINS SHOWER WATERPIPING BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35) CLOTHES WASHER KITCHEN SINK WATERCLOSET BACKFLOW PREV. ($15) _ DISHWASHER _ LAUNDRY TRAY 1WATER HEATER ($35) FOR IRRIGATION _ WATER METER _ OTHER THIS IS AN APPLICATION FOR A PERMIT-NOT VALID iJNTIL PROCESSED I hereby apply for a plumbing permit and I acknowledge 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 permit but only an application for a pe it o k is not to start without a permit on site; that the work will be in accordance with the approved plan in th �� of a� work whic i y ires review and approva �f lans. I' SIGNATURE OF APPLICANT _t��K//" L� PRINT NAME �i G� GGL�G� DATE `� � ( APPROVAL INSPECTORS SIGNATURE T-DATE City of Fridley Building Inspections Department 6431 University Avenue NE, Fridley, MN 55432 763-572-3604 FAX: 763-502-4977