P - 46484Building
Inspections
763-572-3604
?b3-502-4977 FAX
DATE l�' �-�,
SITE ADDI2ESS ��
THiS APPLICANT TS:
OW NERI
TET�ANT
From: 651-925-0070 Page: 2/4 Date: 11l8/2011 12:39:41 PM
PLUMBING
RESIDENTIAL AP'PLICATION
CITY OF FRIDLEY
EFFBCTCVE 1-1-201 l
YOURE-MAILAbDRESS 1'U�,"�I�7 � CQY
Si t��
❑ �WNER
C:UNTRACTOR �AME: ��% �Iu�.�ir+� LGC
St3BMIT A COFY OF
YOUR STATE sTATE L10EN3E #_ ��3' �!"'r �"' %��
LICENSE, BONb AND STATE BOND �
CERTIFICATE pF ADDRESB:�f(JUt► �p�t✓,S �r �.,.,,lz,j�4` CTfY_
INSURANCE
PHONE _ �(��J ' °�l`S � I�'1 Z-� FAX
PERMIT TYPE
TYPE OF WORK: I� NE�'
FAMILY ❑ TWO FAMILY O TOW3dHOUSE
AILED DESCRTPTION OF WORK
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�[tEPLACEMEN?
Perrnit Na. • !
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Received By:
Da�i�'d�
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't�,}�y�z�'-5-�-�
_�xennrE �z 3/ -i2
_ EXP DATE
r� 3TATE�ZIP�
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FEES ARE BASED O1V 510.00 PER FIXTUitE, EXCEPT WHERE NOTED. FIXTURES: (IND[CATE TOTAL NUMBE�t UF EACH BELOW }. MINIMUM FEE
$35.50.
_ BATH S[NK/LAV FLOOR DRAIIVS 3FIOWEli 'WATER PIPING
_ BATH'fIJB GA5 PIPiNG (NEED CTTY LIC) � SWIMMING POOL WATER SOFTNER (S35)
CLOTf�S WASHER �KITCHEN SINK WATER CLOSET BACKFLOW PREV, {S15)
_ DISHWASHER _ LAUNDRY TRAY �WATER IiEATER ($35) T FQR YltkiGATION
_ WATBR METER ,� OTiIER
THIS IS AN APPL(CAT[ON FOR A PERMIT-NOT VALID UNT1L PROCE35ED
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 ardinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applicatio or a permit and work is not to start without a permit on site; that the woric will be in accordance
with the approved plan in the c � �I r quires review and approva� f.plans. /
SitiNANRE OF APpLICANT RINT NAME Z�-Irf /�CN
DATE %I" /
APPROVAL IN3PEGT0�5 BIGNATURE _. na � � i�
�� City of Fridley
. � Bailding Inspections Department
j .� b431 Uni�ersity Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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