P - 48562Building
Inspections
763-572-3604
763-502-4977 FAX
2�12—c���
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
Permit No.:
Received By:
Date Rec' d:
DATE 3 f 6112 YOURE-MAILADDRESS �a� E'Plw���� L4.j Cow.C4.S•�-, �1�'�—
SITEADDRESS 1�65 60*'^ �4v�e.. �'r��� IM,�
1-
THIS APPLICANT IS: � OWNER �'CONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
ADDRESS: /SOS �O`f`� �v�. CITY 'Fr�e%►�d STATE Ll�t ZIP,
PHONE: 6Sl' aZ �'i �I ' �( 4�
STATE LICENSE # (o ( `i ! � � Vt/� EXP DATE
STATE BOND # , � C�c �'F ���-'I' O EXP DATE i i2 ' c� �� 1 3
ADDRESS: L 2D ��'f'� Lh� f�E CITY ��0.:�.�L STATE,]d�ZIP�
PHONE �i�o3' � SR ``�y- I �-i FAX �(23 "� SD'� S 6 i
�ISINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
FEES ARE BASED ON $10.00 PER FIXNRE, 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) SWIr�IIvIING POOL WATER SOFTNER ($35)
CLATf�S WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY _WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OT'I3ER
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 t City of Fr' ley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit an wor not to start without a permit on site; that the work will be in accordance
with the approved plan in the of all w hich r review and appro plans.
SIGNATURE OF APPLICANT � �J'f��� � 6 �u'l����DATE�� �
APPROVAL INSPECTORS SIG TURE ,_ ✓// V
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977