P - 42178Building PLUMBING Permit No.��� ''�
Inspections RESIDENTIAL APPLICATION Received By:�
763-572-3604 CITY OF FRIDLEY va� '
763-502-4977 FAX EFFEC�nvE �-�-zo>> ��tl. � �R�
DATE � �% YOUR E-MAIL ADDRESS
SITE ADDR SS /� ��� ^- J "� � A''��i "� �
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
❑ OWNER �CONTRACTOR
NAME: 9C4-�A�t'' /rI FG( �:`/ Z
ADDRESS: .�� CITY STATE ZIP
PHONE: 7�,�_�/� r 7�c� L
STATE LICENSE #� B��'�j�� T` � EXP DATE
STATE BOND # EXP DATE
ADDRESS:� %3� /�L�Gru'vo,i/ �`"— CITY � STATE '��Z1P �U,3
PHONE ?lv r� o�% �—�oC� � FAX 7G — r`oi -o�Gf9G
d?�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY � TOWNHOUSE
t�REPLACEMENT
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
_ BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SZSFTNER ($35}
_ CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) i FOR IRRIGATION
_ WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL(D 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 the,t il w r w�h�i requires review and appro� f p,l� s. '
SIGNATURE OF APPLICANT 6 ,��i�✓/�'—'�� PRINT NAME /�°��/�ly ��zy�� DATE v l/
APPROVAL INSPECTORS SIGNATURE ne�rF
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977