P - 48158�uilding
Inspections
763-�72-3604
763-502-4977 FAX
DATE r�` jb - l i
SITE ADDRESS I �'i �� �
THIS APPLICANT TS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CEI2TIFICATE OF
INSURANCE
_ PERMIT TYPE
�E oF woRx:
��,ITll�I�I1�T�
�S�El�'��� A��I,�C�'�'��l'�
CI"�'� OF' �'�����
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER �CONTRACTOR
Permit No.:
Received By/`� '`� �
��1�'�-ec��a i� 1 9 L� I i
NAME: 'fQ I L� �-, �y,��� AL ll �-�
ADDRESS: ��i b 6 i�vQ w) v�O L lR.c�_ � CITY � IQ�. .O ( � STATE �`'�'�ZIP �, �i3 Z
PHONE: '76 3•• cS �% �/' •� b � �S..i .
NAME:_(��
STATE LICENSE #
EXP DATE
STATE BOND # EXP DATE
ADDRESS: O�-S a � l D-«- ��'''� CITY .Ft4.t �4 ��_ STATE H�.+ Z,IpSs
PHONE i''t 6� 'Z S` �F ���1 �1 FAX
�SINGLE FANIILY
�m
❑ TWO FAMILY ❑ TOWNHOUSE
� PLACEMENT
DETAILED DESCRIPTION OF WORK �'.N t�A 1 1 �,� I�c�a—, `�� (,, )�o� .t.�. I� t.1—� �r
FEES ARE BASID ON $10.00 PER FIXTURE, EXCEPT WI�RE NOTEA FIXTURES: (INDICATE TOTAL NUMBER �OF EACH BELOVI�. bID�IM[JM FEE
$35.50. �
BATH SINK/LAV FLflORDRAINS SHOWER WATERPIPING
BATHTUB GAS PIPING (NEED QTY LIC) SWIINMING POOL WATER SOFfNER ($35).
CLOTI�S WASHER KTTCI�N SINK WATER CLOSET BACKFLOW PREV. ($1 �
_ DISHWASi�R _ LAUNDRY TRAY =WATElt HEATER ($35) FOR I17RIGATION
_ WATER METER _ OTI�R
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROC�SSLD
I hereby apply for a plumbing permit and I acicnowledge that the informafion above is complete and accurate; that the work will be in
conformance with the ordinances and codes of th City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit d wo is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case of �11 wor which q tr s review and appr al of plans./�
SIGNATURE OP APPLICANT (.L NT NAM� ��n � �� J�..e-,C�"['� DATE -• � - � �--
APPROVAL INSPECTORS SIGNA'PURE �—DATL —
U ��� v� �M�c�ley
�uilciing �ns�e��ions �epa�-�anent
G431 University Avenue NE, Fridley, MN �5432
763-572-3604
FAX: 763-�02-�977
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