P - 39385Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � — S �
SITE ADDRESS
THIS APPLICANT IS:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010 _
E-MAIL ADDRESS
❑ OWNER �ONTRACTOR
PROPERTY NAME: ( �' �c� `�(p.0 1 G
OWNER/ ,�DRESS: CITY
TENANT PHO�: �.��� - � - >�a
Permit No.: �
� - - -• : 11�1.�i�'�
.. :��: a��. _ i i��l �i
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # EXP DATE I�' ��� �I
YOURSTATE -
LICENSE, BOND AND STATE BOND # ��i '3R� 14Af1 EXP DATE
�� V9'il-!1V
CET�'11FICATE UF �Dx�ss: $670 Dodd Rd_ cirY STATE ZIP
�rsuRarrcE PxoNE Eagan, MN 55123 F�
PERMIT TYPE I� SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � �W ��PLACEMENT
DETAILED DESCRIPTION OF WORK CC�"it, lG et�'�Pi���
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV�. MIAiIMUMFEE
$35.50.
BATH SINK/LAV _FLOOR DRAINS SHOWER _ WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMIvIING POOL _ WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
DISHWASHER LAUNDRY TRAY �WATER HEATER ($35) 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 will be in
conformance with the ordinances and codes of the ity of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for ermi d wo k is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case wo d approj' al of plans. p, ?' /�
SIGNATURE OF APPLICANT R1NT NAME c)CD�ME'S C7 I%i�� DATE 7 J�
APPROVAL INSPECTORS SIGNA
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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