P - 60274Building
Inspections
763-572-3604
763-502-4977 FAX
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2012
DATE r►���L- � i �'���- YOURE-MAILADDRESS
SITE ADDRESS I�y I-� G O'� ��JE. �. �.
THIS APPLICANT IS: O OWNER L�ICONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
ADDRESS: � s�i �• 4 0'� I��Vlli. 1(i. �-. CITY FR �CJ
PHONE:
Permit NoQ''0 �,�"W `�`����
Received By�Y '��
Re�c'�d.
1
TATEWL� ZIP 5343�-
NAME: �9 iL NP{i m�G I�} •
STATE LICENSE # QC (� �1�i 13 q EXP DATE 1 2' 3 �•• .iq 13
STATE BOND # EXP DATE
ADDRESS: � 2 � g�'lq7 �-CT� I�'�"� • CIT1' �L{C- ��V i�t� STATEi�'l✓� ZIP 5533p
PHONE �% G 3''�J ��' S 3%'� FAX
`� SINGLE FAMILY
❑ NEW
❑ TWO FAMILY � TOWNHOUSE
�REPLACEMENT
DETAILED DESCRIl'TION OF WORK F�2� ��<Ir�c�� I�ta,��� •��Pt�R��- 1'��L �tiBC�. (" � x-sv��ZS ,�,.Pl�i
1"� P,�nc�t ,�S �i%�:���
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) SWIMIv1ING POOL WATER SOFTNER ($35)
,L CLOTHES WASHER � KITCHEN SINK � WATER CLOSET BACKFLOW PREV. ($I S)
1 DISHWASHER � LAUNDRY TRAY _WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTI�R
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 application for a perm' and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in th o k 'ch re uires review and appro 1 of pl s. '/
SIGNANRE OF APPLICANT � PRINT NAME �AO �Q U{�,A' DATE 7_ 9' J 2-
APPROVAL INSPECTORS SIGNATURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977