P - 42177Building J PLUMBING I Permit No.:
Inspections RESIDENTIAL APPLICATION Received By(�
763-572-3604 CITY OF FRIDLEY a� ��$ � e��11
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE �- IO �// YOUR E-MAIL ADDRESS
SITEADDRESS_ ���$ � �/'�T/Qv P
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
�ERMIT TYPE
TYPE OF WOItK:
❑ OWNER �'7CONTRACTOR
NAME: � CLu I v+ Qv
ADDRESS: �cS��- `!y/�-� /�y,�,
PHONE� �.3 • '� .Z i�- r3� i'
ITY
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A,�.�,►Fss��
STATELICENSE# S'�t�.T�j EXPDATE �p�-��� ��
STATE BOND *#� EXP DATE
ADDRESS: T• O. �Sr l�� C1TY ��G�" STATE�C_ J�ZIPT (
PHONE �7b3' y�/Y-�bZ•�, FAX .�J,� 'F�/�/- i�f � �
�iSINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ 7'WO FAMILY � TOWNHOUSE
�EPLACEMENT
�cv e L
��
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXNRES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
( BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
� BATHTU$ GAS PIPING (NEED C[TY LIC) SWIMMING POOL WATBR 50FTNER ($35)
CLOTHES WASHER KITCHEN SINK T WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER , LAUNDRY TRAY WATER HEATER ($35) FOR [RRIGATION
_ WATER METER _ OTHER
THIS IS AN APPLICAT(ON 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
❑ot a permit but only an application for a permit and work is not to start without a perrrtit on site; that the work will be in accordance
with the approved plan in the case of al work which requires review and approv of plans.
SIGNATURE OF APPLICANT G" ��' L�a.�� ARINT NAME �4C E�✓w � DATE a�✓d �'�(
APPROVALINSPECTORSSIGNATURE - nnTF
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977