P - 39640— O ['1 �-�22
Building PI,IJTl�I�ING perrnit No.:
Ixlspectiolls �i s���i �'�j��, Ap��,���'�'��N Received By: D
763-572-3604 �I�y �� ������ -Date Rec' �
76J-��2�4977 F� EFFECTTVE 1-1-2011
DATE � �- �- 's- � � YOUR E-MAIL ADDRESS
SITE ADDRESS ( 7 �i 4. % �f" d ( ( � �n =� ', .1 � /' N s
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRA.CTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
_ PERMIT TYP'E
TYPE OF WORK:
NAME: {-2 b , j ti C, �, ��'1
ADDRGSS: 1 J� d ���., p(((.� q r, ;„ � �' CITY i-'1a i n l+.- STATE `� W ZIP� S Y�- )
PHONE: '7 �.ii `• ..i %! � � S ��
NAME: j �( t v
STATE LICENSE #J
�t�1.�
EXP DATE
STATE BOND # EXP DATE
ADDRE55: �c� `/ � �i � � �. � �.J � CITY � �/t.i STATE t"1 � ZIP v -�� 3 �
PHONE � b. ?� e S� �(�+ Fi FAX
SINGLE FAMILY
❑ NEW
❑ TWO FAMILY ❑ TOWNHOUSE
:"� REPLACEMENT
DETAILED DESCRIPTION OF WORK ..1 -✓t S'� n� 1 r'� I+� �. _� �k.�- t,� w� i� I•� �� i-'• �
FEES ARE BASED ON $10.00'PER FIXTURE, EXCEPT WI-IERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINKJLAV FLOORDRAINS SHOWER
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL
CLOTHES WASHER �KITCHEN SINK WATERCLOSET
_ DISHWASHER ^ LAUNDRY TRAY �WATER HEATER ($35)
_ WATER METER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROC�SSED
WATERPIPING
WATER SOFTNER ($35)
BACKFLOW PREV. ($15)
FOR IRRIGATION
_ OTHER
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 permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the c of all work w,�'�'ch req ires i view and approval of plans.
SIGNATUREOFAPPLICANT �L-'�-' '� �" "`, PRINTnNAME ���_ i� : �Cc � � DATE ''• -� �" � �
APPROVAL INSPECTORS SIGNATIJRE , I .r n�JS� DATE ,
City oi �'ridley
�uilding Inspections Department
6431 University Avenue NE, Fridley; MN 55432
763-572-3604
FAX: 763-502-4977