P - 40831Building
Inspections
763-572-36Q4
763-502-4977 FAX
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLE�
EFFECTIVE 1-I-20ll _
Permit No.:
Received By:
Da�� d�'
lL'
DATE �- 2-' � � YOUR E-MAIL ADDRESS 1 V\��O � V� o✓�'L� 0.t� a ��.d n � � w� �o ��.�.-.
SITE ADDRESS �--� � 1 S v. e� S�{ (� F'i
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY NAME: '"�w'v� C i�1-� e c i-}rtib; -}n,� �arr 1-�u w.av,�
TENNaN'r •�DxESS: '� � O 1 �-� i'" S k 5� _CrrY_ v�..� 1 s sTATE � NZrn 5S ( i
PHONE: �.r � 2. - 3 D - 1 1� f)
CONTRACTOR NpME; N o,r-i-'h A n o Ic.o, P l k r.,b ;�-.a, L �. c —----
SUBMIT A COPY OF STATE LICENSE � `� ��i L( P�/1 EXP DATE 1 2- -'� �- � 2-
YOUR STATE
LICENSE, BOND AND STATE BOND # `' EXP DATE 1 Z- 3 l^ 1(
CERTIFICATE OF y�DRESS: 22 �^ �j Q(Z ww� R; v�,.- Q I v e� N Y.% CITY S'�' •�*'' a� v� c j S STATE 1+v� N ZIP � ��� 0
iNSURANCE PHONE '�1 b 3-- 7 S 3- 3 3°l 3 FAX "�1 � 3- 2� 3-- � 3 9 a
PERMIT TYPE
TYPE OF WORK:
SINGLE FAMILY
��
0 TWO FAMILY ❑ TOWNHOUSE
D REPLACEMENT
DETAILED DESCRIPTION OF W ORK P I �, w, b�Lw �'1 e�..s �'� �''`" e
FEES ARE BASED ON $10.00 PER FIXNRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
� BATH SINK/LAV FLOdR DRAINS SHOWER _ WATER PIPING
� BATHTUB GAS PIPING (NEED CTI'Y LIC} SWIMNIING POOL _ WATER SOFTNER ($35)
CLOTf�S WASHER � KTI'CHEN SINK � WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER ,� LAUNDRY TRAY �WATER HEATER ($35) FOR IItRIGATION
� WATER METER � OTF�R
_ X.$l;� U�� - �
I. �n� nn _.A�
� . . . � '�. �+V� :!
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 permit and wor i t ta start without a permit on site; that the work will be in accordancc
with the approved plan i , 1 k h requ' re iew and approval of plans.
SIGNATURE OF APPLIC ��i�G� �jdN�i I�,1.ME W� � I i wiv� �- .'��t.v+se..v+ DATE �?- ����,�
"City of Fridiey
Building Inspections Department
b431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977 '