P - 48330Building PLUMBING Permit No.: ' �Z'��
Inspections RESIDENTIAL APPLICATION Received By; /' _
763-572-3604 CITY OF FRIDLEY D���',d :. ������°
763-502-4977 FAX EFFECTTVE i-i-zoi2
DATE ! Z YOUR E-MAIL ADDRESS !
SITE ADDRESS S � /�
THIS APPLICANT IS: �OWNER ❑CONTRACTOR
PROPERTY NAME:�CI L tJl �/� �C{.L %l K t/ L� }
TO NANT ADDAESS: %�Z -S�� �L iP�/�. �� J� . CITY �� � G 3TATE�IP�t[�<
PHONE:�IZ- ��S " rt��l i
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # EXP DATE
YOUR STATE
LICENSE, BOND AND STATE BOND # EXP DATE
CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE pHONE FAX
PERMIT TYPE �GLE FAMiLY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW REPLACEMENT
DETAILED DESCRIPTION OF WORK /v� i, � �� e'L�v_�� �Q �� L�o
FEES ARE BASED ON $10.00 PER FIXTU� EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.5.8. � �
��'"� �ATH SINK/LAV I'� FLOOR DRAINS �SHOWER WQTER PIPING
l/ BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($IS)
DISHWASHER LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
Number of fixtures r� $10.00 �? � $10.�0 — $ �� ��
Number of fixtures ��3 S.OQ x$ i 5.0a =$
Numher of ��iures � $35.04 x $35.00 = $
Stai� Surcharge � ' $ S.OU '
(MINIMU�YI �40 QO) Tatal = $ � 1�`'�°�
THIS IS AN APPLICATION POR A PERMIT-NOT VALID LTNTIL 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 asg ,of- al /work which requires review and approv I of plans. y
', SIGNATURE OF APPLICANT �/�'W��s„�� ` PRINT NAME /�it /�-L�� ��t,.. , t,�r DATE
I APPROVAL INSPECTORS SIGNATURE __ DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977