P - 41193Building
Inspections
763-572-3604
763-502-4977 FAX
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
F.FFF.CTiVE 7-I-2010
DATE �� I�"I - I I YOUR E-MAII. ADDRESS
SITE ADDRESS � t� �`� �e �� F
THIS APPLICANT IS: ❑ OWNER �-]CONTRACTOR
PROPERTY
OWNER/
TENANT
ADDRESS: CITY,
PHONE: � � "� �L) �J " � � � �i
Permit No.:
Received By:
�te�e�� �
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CONTRACTOR NAME: lF';��j�jRy� ���p��lp��
SU$MIT A COPY OF STATE LICENSE # # 6177n-Pnn EXP DATE
YOUR STATE
LICE:`TSE, BOND AND STATE BOND # 651-365-1340 EXP DATE
CERTIFICATE OF e,DDRESS: 3670 DOCIC� RCI. CITY STATE ZIP
�rsux�cE rxorr�, an, 3 Fa�c
PERMIT TYPE
TYPE OF WORK:
I�SINGLE FAMII.Y
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
�PLACEMENT
❑ TOWNHOUSE
FEES ARE BASED ON $] 0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMi1M FEE
$35.50.
BATH SiNKlI.AV _FLOOR DRATNS SHOWER WATER PIPING
� BATHTUB GAS PIPING (NEED CITY LIC) SWIMIVffNG POOL WATER SOFTNER ($35)
� CLOTHES WASHER HITCHEN 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 iJNTII, PROCESSED
I hereby apply for a plumbing permit a�I acknowle e that the information above is complete and accurate; that the work will be in
conformance with the ordinances and code f the ity f Fridley and with the Minnesota Construction Codes; that T understand this is
not a permit but only an application f a pe 't d ork '.not to start without a permit on site; that the work will be in accordance
with the approved plan in the case d�pprova of plans. � ��� j_ C+
SIGNATURE OF APPLICANT T �,�.� .��ATE �
APPROVAL INSPECTORS SIGN:AT
_-_ vt �`nC��.Tt]T�• c�AeA e: F`PFR , RF(17 FTl F'(1R RTiTT.TiTNC"taFi.F.CTRTCAL`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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