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Inspections
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763-502-4977 FAX
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Si1BMIT A COPIf OT'
YOURSTAT�
LTCEN5£, B4ND AND
CERTfFICATE OF
INSURqNCE
PERMIT TYpE
TYPE OF �'VORK:
From: 763 213 1 390 Page: 2/3 Date: 1/24/2011 2:09:08 PM
PLUMBING-
Permit :\�o.:
RESIDENTIAL APPLIC'AT`jpN Received By:
CITY OF F�2IDLEi' e xx��"��
EFFEC'TTV� 1-1-20I1
YOURE-bL4(LADDRESS �fi�2 Et��%[`�2`�+Ct.nc�^i-t. l�crk�oil< : Lr,,:
���= ?� R ��: Sr- r4�'r.
LI OLl'NER
NAI�fE: �...F��Gi .a.� %A�� �+
�DDRESS: ��tc 1 la �iAv� �u�e.h �" f�) � CIl'Y �"'�� ��..c. � STATE�i4.�'rZIP
PHpNL•._ � irc3 % ? �(c " �{ '^! S.� �`—
3TATE LICLNSE k S`� �% �" l� �'rl �XP DATE � al 3 i f i oi
STATE BOVD il `.�i l �'�'� EXP DATE __�� �.31 � i
ADDRESS� �SiC�'3 ,v, ��e'�2 � at2 C�• S'�� S"Q�a�%\,.i� STATE ��ilJ 7_]P ����i{�i�
esoh�, �rr3 -� 53 - 33 � 3 F�ix �7�"r.3 -� i 3- i 3`? C�
�f 'sINGLE FP,MTLY
���
❑ NEV.�
DETAILED DESCR.�°TION OF V�%QRT�
---- ca.+r� c�i E.3.�-�ct <
❑ 1'VT(J FAMTC,Y � TOWNHOUSE
�d RL-PLACE1LfENT
/�
�
FEES ARE BASED ON $1G.06 PER FIXTURE, EXCEPT i�'HH]2E NOTEp. FIXIL72ES: (INDICATE "C(7TAL NUMBER OF EACH BELOW). hf1N[Iti•NM FEE
S35.SQ.
� BAFH STNK,'L:�V _Fi00R DRAINS
�BATTiTllB GAS PIPING ChI&Ep CITY LIC) �SW1�µML'�t[NG PQOL
_ CLOTHES �t'nSHER ,� KITCHEV S7NK i 4L'ATER CLOSET
,, DISHWASH£R _ LACJ?�IISRy I'Rpy 1'YVA'fERHEATER ($35)
� 41'ATER METER
Number of fixtures @ $1 QAt� `� x $14.04 = $ �fi+CC�
�(umber of fixtures @ $iS.Ofl x $1�.00 = �
l�TUmber offixtures @$35.00 � a$35.00 =$.�S. G;C?
State Surcharge S 5.00
�M
=� '�5T"i• CC�
VYAY'ER PIPII�'G
i LVA7ER SOFTNER (S35J
�BACKFLO�'t' PREV. (S15)
� FOR IRRIGATION
_„_ OTHCR
TiiIS IS A�i APPLCCATION FOR A PEFLI�IIT-VOT VALID UNTCL PROCESSED
T hereby appiy for a plumbing permit and I acknowiedge that the informatian above is complete and accurate; that the work �v�31 be in
cooformance with the ordinances and codes of the City of Fridley and with the Miruiesota Constr�ccion Codes; that 7 understand this is
not a perrnit bnt only an applicatian for a pQrmit and work is not to start without a parmit on site; that the vrork wiil be in accordance
with the approved p(au in the� of al1 w- hi requires reviev�� and appro�f pl�.
SIGN iT[rRE OF APpLICAVT .�--��j �',je
APPRO��AL L\'SPECTORS cr�:u TT�AFi-� � , _ P��1� NAA� f,`°' ,,/�''r✓s`'.•J __ DATE � i�'� I t 0
P
,�RATB
City of Fridle�
Buildin�g Inspectaons Department
�i4 i 1�Jniversit�r Avenue NE_ FridRey_ 11iERI S Sd :'>
76�-572-3604
FAX: 763-502-49'�7
1�'ORI�