P - 48241C'r� �SS"2--
�tiilding �� ;�J���� �
�nspections �����I�?��� �.����� � �'��1�
763-�72-3604 ���� ��' �'����+ �
76�-���-�977 F`�i �FFECTIVE ]-1-2011
DATE Z-�- �� YOUP� E-i�IAIL ADDRESS
SITL ADDRESS � S�� �^� 4-✓�"� �• N�
THIS APPLICANT IS: � OWN�R �CONTRACTOR
PROPEYtT�,'
OWNER/
T�NANT
CON�'RACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE. BOND AND
C�RTIPICATE OF
INSURANCE
_ PERMTT TYPE
TYPE OF WORK:
1t No.:
Received Bti�:�
Date Rec'd;,��
NAME: �i 1t4b1.��^ /v �' l R.i�'�-�'�''
ADDRL-,SS: 7 S�( ��I N � li. �,., c� N E CITY �� ��D( �, STATEt`4� ZIP_
PHONE: � �� � � a � ' �j � � S
NAME: Y�t vw C�- i Ptv-�-�.�Oi"�
STATE LICENSL � EXP DATE
STATE BOND # E�'P DATE
ADDRESS:�Z�� 1'I�t4 S�- w�E CITY ��¢..�iOI<< STATEt"�'`� ZIP JSti3�--
PHONE ,2�, i s�I e1 ��( � PAX
�SINGLE FANIILY
❑ NEW
DETAILED DESCRIPTION OF WORK
E
❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
�t w
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOORDRAINS SHOWER WATERPIPING
BATHTUB GASPIPING(NEEDCITYLIC) SWIMMINGPOOL WATERSOFTNER($35)
CLOTHES WASHER KITCHEN SINK WATERCLOSET BACKFLOW PREV. ($IS)
_ DISHWASHER _ LAUNDRY TRAY j WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTI�R
_ _ . _ _ r "r _
State Sureharge � 5.fl0
(1VIIlYIMiTM �40.00) Tota1= $ � � � � `'�
THIS IS AN APPLICATION FOP� A PERMIT-NOT VALID CNTIL PROC�SSLD
I herebv app]y for a plumbing permit and I acicnowled,e that the information above is complete and accurate; that the worl< 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
i�ot a permit but only an application for a permit and worlc is n to start withotrt a pertnit on site; that the work will be in accordance
�vith the approved plan in the case of all wo k which requires r iew an�approval of_plans.
SIGNATIJP�6 OP �1PPLIC,'�NT 1.�1. � PRIN�T�'Vl�nn� Cr•.� w ✓Z�,.+-� o�TE ld • a- �- �I �
:1PPROVAL iNSP�CiORS SIGNA�'UR� � �'� DA"I'L �-- L
PLEASENOTE: SEP,4Rr�TE PF Mi S;. RE tJIRGD.F R SUILDfNG. EL�C"TR[�.AL AND V[ECHANI ,�1L WnRI�
'ti 1�'� aY Ti P1 �C��P.�
��i�c�in� insoe�iIlOns I�e��r*pne�$
6�31 Universitv Avenue NE. Fridle�,�. V1I'J �=�?�?
76�-5 i�-3604
FA��: 76�-� 0? _�?97 �