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From: 763 585 4547 Page: 1/1 Date: 5l2/2011 10:59:29 AM
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APPLIC NT 1S;
' PLUMBIN+G
RESIDENTIAL APPLICATI+(�N
�ITY OF FRIDLEY
EFPECTIVE t-1-2011
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�}VdNER
ADDRESS: I�j I C"1 S C.� ���' s-t ����.-�-i'�CtTY
PHONE: �� C7 � " �A S " � S��T
ONT CTOR NAME:_.�_�
BMiT A OPY OF gTAi'E LiCEVSE #
Y4UR AT�
ENSE. 8 ND AND STATE BOND #_,
ERTCF[ TE �F ADDRESS:
lNS NCE pHONE
,�.�� �LI S[TGLE FAM[LY
❑ NEW
DESCRiPTION OP WORK
_ _ �... ,-�., ��' � ���,
❑ TWO FAM[LY
�REPLACEMENT
Permit No.: fL� l l�'
Received By:�
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C7 IYtSfti .
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EXP DATE
BXP DATE
CITY STATB ZtP,
FAX
❑ TOWNHOiJSE
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S ARE B SED ON 510,00 PER FIXTURE, EXCBPT W7-3ERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACti BELOW}. MINIMUM FEE
Sa.
BATN SI ICiZAY FLOOR DRAINS SHOWER ATER PIPING
BATH7U � GAS P1PiNG (NEEb CITY Li� � 5W[MM1NG POOL _ wATER SOFTNER ($35)
CLOTHE VVASHER � KiTCHEtQ SINCC ! WATER CLOSET BACKFLOW PREV. ($15}
DiSHW'A HER T LAUNDRI` TRAY �WATER FIBATER ($35) � FOR [RRIGATION
WATER MET6R _ OTHER
a pe
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es � $3S.OU x $35.00 = �
e $ 5.00
54�.00 Tota1= $ �-{ 4 . QC�
TEDS IS AN APPL[CATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
pty for a plumbing permit and I acknowledge that the is�formation abave is complete and accurate; that the wock wiyl be in
�e with the ardinances and codes of the City of Frid.ley and w7th the Minnesvta Construction Codes; that [ understand this is
t but only an ap � ion for a perm' a ork is not to start without a permit on site; that the work will be in accordance
�toved plan in�,���,�e o i re uires review and app�l f fa�- �`.,��~ �,, ��� t
UF APPLICAN PRINT NAIv1E ' r �' 7 DATE
pYSPECCORS SIGNATURE DATE �
Td�TE_ SEPARATE PERMfTS AR UFRED FOR B ILDING, ELEC'TRI�CAL AND MEC WORK
City of Fridley
Building Inspeetions D�partment
b431 University t'�venue NE, Fridley, MN �5432
763-572-3604
FAX: 763-542-4977