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Building
' Inspections
'763-572-3604
' 7b3-502-4977 FAX
DATE � l ,� �� ��
SITE ADDRESS �_—
THIS APPLICAN7IS:
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From: 6506556633 Page: 2/2 Date: 9l8/2011 1:45:36 PM
To: Fax: +1 (763) 502-4977 Paga 2 of 2 9!8/2017 1:42
PLUMBING
RESIDENTIAL APPLICATI4N
CIT,Y OF FRIDLEY
EFFECTIVE 1-1-2011
YOURE-M.AILADDRESS �t"'r kC.'Ll�i I�
Q at�'NER `�TiTRACTOR
K�i ����
s: (p�+.� t i R►'c�.►' �l-�-t 3�c- n.;E. c�rv
?��--.5 7�/-7.S�Q'�—
-r�l � y � - - � f _ .._. , _ . _
SUBMIT A COPY OF Srp�rE LICENSE ��p�
YOUR STATE ,.�
LICENSE, BaND AND STATE BOrD i� Gj?� 1_f
CERTIFICA'TE OF' A]DDRESS:�S�
ITSURANCE AHONE I�13�^ �,Sr�-
PERMIT TYPE
TYPE OF WORK: ( � ���'
FAX
FAh9II.Y O TWO rAMILY ❑ TOW�IHpUSE
DETAILED DESCRiP'{'ION OF Vt�ORK
Fermit No,:Lv�
Received By �
°��'���
�n.ar��a-3 i-2ota
EX.P DATE
STATE�_ZIP�(
FEES ARE BASED ON $10.00 PER FI}CfURE, EXCEPT W'1�RE IvOTED. F1X7URES: (INDICATE TOTAL 1JLRvlBFR OF EACH BELOW). MINIMUIoi FEE
$3�.50.
BATH S[NK/LAV FLOOR DRAITIS SIiOWER WATER 1�!1PiN�C'i
_ BATH7U8 GAS PIPING (NEED CTTY L]C} � SWZ�IMIIr'G POOL �WATFR SOFTl�EFt (S35)
CLC1'Tf�S�VASHER KCfCHEN SI1+iK �'1'ATERCLOSE,T BACKFLOW PREV. {S!5}
_ DISHWASFIER _ T,AUNDRY TRAY WAiER HEATHR ($35) FOR IRRIGATiOM
WATFR NfETER OTHER
THIS TS AN APPLICATION FOR A P6R�i1T-NOT VAL1D UN7T[. PROCESSED
i hereby apply for a pluznbing permit and I ow4ed e at the information above is complete and accurate; that the work will be in
conformance with the ordinances and cod of t Ci of ridley and with the Minnesota Construction Codes; that I undeistand this is
not a permit but ont}� a aiion for a k is not to start wiihout a permit on site; that the work will be in accordance
with the approved plan in t e of al' review and appr i of p[a,n� �(� 1
SIGNATUR£OF APPLICAT�7����� I\_ . . � �5���� DATE � //,/1 "/�
� c�ry ofF►��a1�y
Building Inspections Department
6431 University Avenue NE; Frid.ley, MN 55432
763-572-3604
PAX: 763-502-4977
11