P - 48407Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ,-�C -�-�, ,( ` /
SITE ADDRESS �
THIS APPLICANT IS:
R Y
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFEC7TVE 1-1-2012
- YOUR E-MAIL ADDRESS
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O OWNER �C�ONTR.ACTOR
Permit No.: /.�± Y (i (� (� � `'l`��
Received By: + �'- � �`j �'�
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Date Rec'c�"' �� � s - - '
PROPE T NAME:
OWNER/ ADDRESS: CITY STATE ZIP
TENANT
CONTRACTOR NAME: A// /�!�lLiG�� ��G>iy1 �✓'i s/��
SUBMIT A COPY OF STATE LICENSE #� �/�J� 9/�,/YI J EXP DATE
YOURSTATE
LICENSE, BOND AND STATE BOND # EXP DATE
CERTIFICATE OF ADDRESS: y���/ �� ��/'�6°'�' ./UG" CITY /�D�2P,ST��/rf'- STATE�ZIP t�S
INSURANCE pHONE i�� -��-5 �SS�S FAX E'S�-Y��-Crv2S��
PERMIT TYPE I �LE FAMrLY
TYPE OF WORK: I� NEW
❑ TWO FAMILY ❑ TOWNHOUSE
�,�EPLACEMENT
DETAILED DESCRIPTION OF WORK %'��v'�r G� ry�, T�i.� ��WC�{ �-� %�l�� %7� �T���Li¢��
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (1NDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
� BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
� BATHTCTB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTf�S WASHER KITCHEN SINK � WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TR.AY WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
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�i,�.,,#,n,-r.���-t„r�� /hl i"lfi Elfi� �.�.C7tl (1f1'_ iC ...�,. � ``..- � , . .
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a}�ermit and work is t to start without a permit on site; that the work will be in accordance
with the approved plan in the case „�ai1"work,zv req.i.iires iew and apprqya] of plans ,
.. y�
SIGNATURE OF APPLICANT - % • PRINT,P�AME /%°c� / % /�.S/E'/ DATE cr� � / -.�_ .�
APPROVAL INSPECTORS SIGNAT E�% , A� ,--T� DATE /� /� ; , , �->_ -_
` City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977