P - 45117From: 9522558603 Page: 212 Date: 11/12/2010 9:51:29 AM
�uildi�xxg P��J�S�NG �'errz�xt 1vo. C it
�ns�ec�oz�s �SID��TTIAL ,AP���CAT�t�N R�G�xv�d �y: �Y
��3-s�2-��a� �IT� t)�' FRI�LEY ��5���� 1
7�3-SV2-47/ / �t'1.A crvnrrn�c�_t_�ntn
SITE ADDR�SS � � (�/� f� /A
T}IIS A,PPiICANY" 15: ❑
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CON'�'kiA.CTOR
SU9�vt�' A COP'Y OF
X�UJFL S'�A'�'E
�.ZC�E�S�, BOND AND
CERTTFICA,?� 0�
INSUItANCE
FE��'x' '7.'X��
TYPE U�' WU�:
STATE I,ICENS� �_
SxA'Y'fi BOND # ,�
A,pATi�SS��;
��ONB ��
�] S1NG�.E kAZNZ�.Y
B NEW
�7�'�,A.IL�D DESCRIYTIDN 0�
L3 TWO FA,�I1.X
���z.ACkMENT
FA�X
n �rowav�ous�
�XP DA'E'E
�XP DATE
FEE3 ATtTc BAS�A �IV $�0-00 7ECL FIXT[JRE, �7�C��� WFIERE NU7�JJ. IF7J�'fCJRfiS: (fNi]FCATE Z'OTA�. N[1��ER OF EACli �E�.OW). MII�IMUM F��
535.50.
BAiH SINK/I.AV FLOOTt 1722AiN8 SHOV4�R WATER PIPiNG
_ �ATfITUB _ ("iA$ PiPING (NEED ClTX �.xC) SWIMMING QOO�. � w,ATER SOFTNER ($3S)
C�O'�}35 WA,SkJ�R Ki'�'CI�EN SxNJC � WA,T�R CLOSET BACKFIAw ��.V. (�l5}
_ AxS�VJA,S�R _ 1.,AiJNDRY T�t,AX _WATE�i �a.A,�� (E35) ' �OR tRRFCvATION
� WAT��i �T�1� _OTf�R
Numbe,r o��'iacnues @ $lO.Op � x $� 0.00 = �
Nutnbex o�f �xtu�'es � $ISAO x ��5.p0 = $
�(u�nber af fixtures @ $35.00 ` M $35.00 = $
State 8urcharge
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f
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TFII9 IS AN APP�.�CA�OIV kOxt, A�'ERMiT-NOT VALID UNTI�. PROCk.SS�A
1 hereby a�ply �or a plu�biu�g permit and I aeknawledge that the ���onxtatio�, above is eomplete and accu.rate; that lhc work will bo iup,
cotz£oxioatat�ce wz� tk�e ordanances and codes of the City of Fridley �d with tJae �z�esota Canstructiqn Codes; t�at I understand this is
not a pe�xt but ox�ly au ap�1 weation for a perntrt and woxk is x�ot to start withaut a permit on. site; tb�at the work will be iz� accoxda.nce
w�it,� t�e appFavc� plan in �j wark w,��ckt requires r�view and app��vs�o�as�.� ��� Da-r6 �li I'LI I d
6[CNAT'URE OF APPLICANI'IL��i PR2NT NAME � A t
� City of Fridley
BuildYng �nspec�k�ans pepartment
643 � Unir+ersity Avenue �iE, ��zdley, MN 55432
763-572-36Q4
FA�: '763-502-4977