P - 42377Building P`��.T���l��
�nspecii�ns �ES�D�l��'��L A�����A�`�Ol"�
763-572-3604 �I�� �� ������, �
763-502-4977 FAX EFFECr�v� i-i-2o�o
DATE �/ �'1
SITE ADDRESS �
THIS APPLICANT IS:
PItOP��tTY
OVVNER/
T�NANT
YOUR E-MAIL ADDRESS
17 OWNER 'E�CONTRACTOR
NAME: J�/\ � Cihl.� P.�'�( �
ADDRESS: ��TY
PHOl3E: �{U '3 � � ''T � � � _
�
Permit No.: . �_
Received By: ` `' �
Dat��. �'d:�'
STA'
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # �# fj'I �Z7O-P�M EXP DATE
YOURSTATE
LICENSE, BOND AND STATE BOND # �67Q D�-1340 EXP DATE
CERTIFICATE OF ADDRESS: ' CITY STATE ZIP
INSCJRANCE pHONE a ' FAX
PEktMIT TYPE `F SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: D NEW � REPLACEMENT
DETAILED DESCRIPTION OF WORK
FEES ARE BASED ON $]0.00 PER FIXNRE, EXCEPT WHERE NOTED. FIXTU2ES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMIIM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SNOWER _ WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWTMMING POOL _ WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($IS)
DISHWASHER ! LAUNDRY TRAY �WATER HEATER ($35) � FORIRRIGATION
— WATER METER _ OSHER
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 City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an appiication for a permit and work is not to start without a permit on site; that the work wil( be in accordance
with the approved plan in the case of all work whic�h �equires review and approval of plans. � ��
SIGNATURE OF APPLICANT
�fty of �ridl�y
Builciirng Inspeetio�s Dep�rtrrae�at
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
♦
�'b�'0�
�ll