P - 84364Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � ''� � ` ( Z-
SITE ADDRESS t
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-2012
YOUR E-MAIL ADDRESS �
�
❑ OWNER �7E6'1Q�'RACTOR
Permit No.:/iU����
Received By
� . �.�.� ;-� ������ - - � i �i
y, c�,m
ADDRESS: CITY STATE ZIP_
PHONE:
NAME• I L�r'1.}7i +.r� LL- �.
STATE LICENSE # (`� ��(�,��� EXP DATE �Z "3 I` � 3
STATE BOND # EXP DATE
ADDR�SS: �`z �1 3 �G''� % ��`"� C►TY Z ' +�+�"4 � �� "'°1 STATE ZIP
PHONE �o �L ` ,� � C� _ � � �� % FAX
TYPE OF WORK: I� NEW
FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
DETAILEDDESCRIPTI N OF WORK 5�`t" /V'�.�✓ �'���1`�'w�l'3 �4✓J $�-�� �''��- ���`�fL
���.-t--h ���-�, c�c �,�-�� 5' fi-�. ;�3
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED.
�i BATH SINK/LAV FLOOR DRAINS
Z BATHTUB GAS PIPING (NEED CITY LIC)
( CLOTHES WASHER I KITCHEN SINK
� DISHWASHER � LAUNDRY TRAY
FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW).
SHOWER
SWIMMING POOL
� WATER CLOSET
1 WATER HEATER ($35)
WATER METER
THIS IS AN APPLICATfON FOR A PERMIT-NOT VALID UNTIL PROCESSED
WATER PIPING
WATER SOFTNER ($35)
BACKFLOW PREV. ($15)
FOR [RRIGATION
OTHER
1 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 work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the c se of all work which requires review and approval of plans.
—'—' �j V �G�'� 2–1
SIGNATURE OF APPLICANT --�� PRINT NAME �' �w'� ���� Lh DATE ! Z-
APPROVAL INSPECTORS SIGNATURE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
DA'