P - 48599�uilding
�ns�ectians
763-572-3604
763-502-4977 F�X
DATE (�— �
SITE ADDRESS �
THIS APPLICANT IS:
PRQ�ER'I'Y
�����
'i'EN�IT
�o�'��.c���t
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
P��I�T T�'P�+
TYPE OF WO�%:
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F.FFECTNE 7-1-2010
YOLiFt E-
❑ OWNER �ONTRACTOR
NAME: T�.0 Y)C)Y 1
ADDRESS:
PHO� 1�3- 57� -
�1�
Permit No.��t,+�'��O � � �'
Received By: �' �'/ -� i' 1-^�
Dat��: `� � � �. � `,`
NAME �;h�mpion ��It��bi���,�
STATE LICENSE # M EXP DATE �Z�� %/
STA"fB BONTJ # ��
Eu- iiATE
ADDRESS: - n�ITY STATE ZIP
PHONE
�INGLE FAMII.Y
❑ NEW
DETAILED DESCRIPTlON OF WORK
❑ TWO FAMILY
.�ZEPLACEMENT
FAX
❑ TOV�R�iOUSE
FEES ARE BASED ON $10.00 PER FIXTURE, E3iCEP7' WHERE NOTED. FIXT'iJRES: (INDICATE TOTAL NUMBER OF EACH BELOW). NIINIMZIM FEE
$35.50.
BATH SINK/T.AV FLOOR DRAINS SHOVTER WATERPIPING
BATHTLTB GAS PIPING (NEED CITY LIC) SV✓IIvIMING POOL WATER SOFTNER (�35)
CLOTHES WASHER i KITCHEN SINk WATER CLOSET BACkFLOW PREV. ($1�)
DISI-IWASHER LAUNDRY TRAY _WATER HEATER ($35) FOR IRRiGATION
_ WATER NLETER � OTHER
Number of fiatures @ $10:00 x $10.00 — $
Number of fixtures @ $1�.00 _x $1�.00 — $
Number of fixtures @ $35.00 � x $35.00 $
State Surchar�e $ `' S.00 "
fA'FIN�1�'�Ul�'d ��0.001 Tota1= $ �'C� i W
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII. PROCESSED
3
I hereby apply for a piumbin� permit and I acknowled�e that the infoiznation 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 f a p it an orl ' not to start without a permit on site; that the work will be in accordance
with the approved plan in the case ' � d p�rcrnat-of olans.
SIGNATURE OF APPLICANT T h?ANIE DATE "I
.APPROVAL Rv'SPECTORS SIGNAT �/��� �
:` PLEASE NOTE: SEPAR E PEr �u''i �__ v��U"�=,� �Gn BUILDING, ELECTRICAL AI�TD A�CHANICAL WORK
�&� d� '�' i'P���y
��iiePi�g �r�sge��r�rns ��p��°�r��mt
6431 University Avenue NE, Fridley, MN 5�432
763-�72-3604
FAX: 763-�02-4977
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