P - 43836Building PLUMBING
Inspections RESIDENTIAL APPLICATION
�s3-s�2-360� CITY OF FRIDLEY
763-502-49%% FAX EFFECTIVE 2-19-09
DATE
SITE ADDRESS _
THIS APPLlCANT [S:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SLIBMI'f A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIF(CATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAIL ADDRESS
O OWNER OCONTRACTOR
.•:;�
- d�' ClTY
PHONE:
NAME:_ (�ICQ.. il�u�^' Cw+O�r fiU�t « 1� r�-
STATE LICENSE q
STATE BOND #
ADDRESS:�
PH013E ?103 — �
O SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
O REPLACEMENT
� GW / .b►-►, r�ti �.
Permit No.:;,, ��� I' I r' ! ��
Received By: '
D������":�u 200!
A
EXP DATE
EXe DATE
?� STATE(�ZIP �
_ FAX
O TOWNHOUSE
e,r .sc,�k.� ( v+.c� v,�l
U�/'j.2__
FEES ARE BASED ON SI0.00 PER FIXTURE, EXCEPT WHERE NOTED. FfXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINiMUM FEE
535.50.
_ BATH SINK/LAV FLOOR DRAINS ' SHOWER /b WATER PIP(NG
,_ BATHTUB GAS PIPING (NEED CITY LIC) S WIMMING POOL WATER SOF7'NER (S
_ CLOTHES WASHER _ KITCHEN SINK ! WATER CLOSET BACKFLOW PREV. SI )
_ DI5HUVASHER _ LAUNDRY TRAY WATER HEATER (S35) FOR IRRIGATION
_ WATER METER OTHER
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 wili be in
conformance with the ordinances and codes of the Ciry of Rridley and with the Minnesota Construction Codes; that 1 understand this is
not a permit but only an application for a permit and worlc is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case of I work w'cp-re�quires review and approval of plans.
s° n > �"�
SIGNATURE OF APPLICANT�"��'J PRINT NAME� � Wl 47 �m I�,/r vVK. DATE_ JI 'a� O�d %
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, M1V 55432
763-572-3604
FAX: 763-502-4977