P - 45113Building
Inspections
763-572-3604
763-502-4977 FAX
FLL�IVI ING
SIDENTIAL A.FPLICATItJN
CIT4� C�F �RIDLEY
EFFFCTiVE 1-1-241 i
Perrriil No�.�i,�
DATE � ('� '� YC)t'R E-tviA(L .4C>DRESS
siTE AnDaESS 5571 WaldeCk Crossinq _ _ _
TH1S AFPLiCANT IS�
owN�w
TENANT
CONTRACTOR
sun�nr�r � coPY or
vou� s���A�r-F
LICENSF. [30Nb AN])
ct x�r��ric.a�r�: or
INSURANCF.
PERMtT TXPE
TYPE OF WQRK:
❑ ()W'!�ER $1CONTRACTOR
�:
�
. _: �
A7xME; UUfiS VIIt(1(I1CI
nn�Ress _5571 WaldeCk Cross�ng ,__ cre�' Fridfe� s7�TEji��rn 554,�
_ ._..
PHONE: __.��� .�7�_..�...�I,.�Z.._..._. __�...........�,�_.....
rson riumnina, inc.
STATE LICENSE � 58757 3341 PM Exr onrE 12/31/11
STATE BOND # EXP DATE
_____...� __ _ __...._ m_._. _.�,� _...,...,.�
,�n��ss 3095 162nd l.ane NW c:��� Andover s�c.q�reMN z�►� 55304
pxor�c 763-427�7680 �� �� Fax 763-427-9448
� SINGLE FA�tIILI`
❑ NEW
❑ T4�'(} Ft1!�#!LY ❑ Tt)1§`NHt}ttSE
IS REPLACEh1ENT
DETAILED DESGRIPTIC}N OF WORK Replace Water Heater
FEES ARE SASED ON $10.0a PER FIXTLiRE_ EXCEPT WHERE NOTEQ, FIJCTLJRES; IINDICAiE Tf?TAL NIJMBEii OF EACH BELOW) MINIMUM FEE
$3 �.50.
BATH S1NKiLAV FLOOR DRe1INS SHOWER WATER PIPINCi
BATH'I'EJB GASPEPINCi(NEEDCITYLIC) SWIMM113C'POOL 13ATERSOFfNER($35)
� CLC)THE� WASHER KE7'CHEN S1NK W ATER C LUSEf � BACYCFLOW PREV. (S I 5)
� DtSHWASI-EER _ LAUNDRY TRAY �,WATER HEATER ($3i1 FOR IRRIGA77(mi
_ WATER METER _, OTHER
TI[I5 [S AN APPLICATION POR A PL•ItMIT-I3C?T VALID iiI�lTIL PRUCLS4LD
I hereby appiy for a pEumbing permit and 1 acknowledge that the information above is complete and accw•ate; that the wo��C will be in
conformance with the ordinances and codes of the City of Fridley and writh the Minnesota Canstruction Codes; that 1 understand this is
not a pemiit but only an appl��ation far a perm' and work is not to start without a pennit on site; that the work will be in accorcEance
with the approved plan in th ase of all �noii c w ich �quires rev�ew and approvaf of plans_
SIGNATIJRE OF APPLICANT ��%(,� `� ' !( %��i�PRfN'r NAME ''�7'�2LJ ��"� (/��� f nATE _
APPROVAL INSPEC'I'ORS. : ATliR � . �� s.': ,/\ —�T— DATE � Q , __
City of Fridley
Building Inspections Depar-tment
6431 �;niversity Avenue NE, Fridlev, MN 55�32
763-57?-360�
Ft1X: 7b3-502-4977