P - 42755Building PLUMBING Pennit Ivo,� (� � � ' �
Inspections RESIDENTIAL APPLICATION Re�ei�ed By: �
763-572-3604 CITY OF FRIDLEY Date Rec'd: (� �
763-502-4977 FAX EFFECTTVE�-i-zoio
DATE I �Z� �2 / r � YOUR E—MAIL ADDRESS � � �.., � � e�' ; �}C � y� �'� �t'� Ci—�
sITE ADD�ss j t/ �/ y `/ fi` %� � i'� � .� � : � i ..,
THIS APPLICANT IS: ❑ OWNER �1CONTRACTOR �
PROPERTY NAME: �r.nL d i,.;ti:,,,.�._ �j,,���a��
OWNER/ ADDRESS: I� CI � y� � CITY f�
TENANT � � �x--�-� S'ra'rE"i`�f•� z[r�"��o�
PHONE: `7 � _� "'S 7 � " �"S' �1��✓
CONTRACTOR NAME: �c„nit� � iK. I��l
SUBMIT A COPY OF STATE LICENSE �(u —i ? S_� '— P 1— • EXP DATE � I,� 31 /� c� i i'1.
YOUR STATE a
LIC$NSE, BOND AND STATE BOND # EXP DATE
cER'rr�CATE oF A��xESS �� S`7 7 1� ���` S+� �i'TV Z�; n��n.c�N��..� sTATE_ t�1�YzIr 'S 3�
INSURANCE pHONE ej�� 3� %� ivO� �/ FAX
PERMIT TYPE NGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW �KEPLACEMENT
DETAILED DESCRIPTION OF WORK �G I � � �� � Gw � �� {-� : n1 '"7`� . �C � � 1 '�}u.,,.' �._,
Q/� � ��,.e. �vL� %h -.�_�--;. -�: +.�- �� .� 1 S 1�► a�,.�✓
FEES ARE BASED ON $10.00 PER FIXTCJRE, EXCEPT WEIERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
� BATH SINK/I,AV _FLOOR DRAINS SHOWER WATER PIPING
� BATIIT[IB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK � WATER CLOSET BACKFLOW PREV. ($15)
DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
� f�x�
NtiAibei of flXtteTes +n $t4:40 � ' X $10.� = $
Number of fixtures @$15:00 ' x$1 S.O0 ='$
Number of fixtures @ $35:00 x $35.00 = $-��
State Surchazge $ 5. �
iNIMUM $40.00 Tota1- $ ��
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 work is not to start without a permit on site; that the work will be in accordance
with the approved plan in th e f all which requires review and appro of plan , i
SIGNATURE OF APPLICANT � PRINT NAME �c� . � � '-(J 't, � DATE 1 � �� " I �.%
APPROVALINSPECTORSSIGNA
PLEASE NOTE: SEPA TE PERMITS ARE RE D FOR BUIL , ELECTRICAL AND MECHANICAL WORK
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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