P - 40704Building PLUMR►ING permit 7vo.:L.� I I� I��
Inspections RESIDENTIAL APPLICATION Received By:�
763-572-3604 CITY OF FRIDLEY r�ate
763-502-4977 FAX EFr�crrvE �-�-ZO� 1 ���� '����"�
DATE ��3 �"�I,/ YOURE-MATLADDRESS
SITE AADRE3S -� � �i �" � � ���� ,N �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
BUBMTP A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFfCATE OF
INSURANCE
PERMIT TYPE
❑ OWNER
rrAn�: ru_r___ti a� ..c �-��-r-.c r� �n G n A,���
ADDRESS: � % � � �.^% ^� CITY r7 /l �(�/ �� STATE /•WG1P.
PHONE: 3� j �� C� a/� %
NAMR• �Iw i! �i.. M h/ n. t� /7`L �:� �.n . L L- C
PHONE %��, U i O ? 3 S�- FAX
TYPE OF WORK: I ❑ �Ew
FAMILY ❑ TWO FAMILY
�PLACEMENT
DETAILED DESCRIPTION OP WORK �"i [�/ ac t--
❑ TOWNHOUSE
�
� r'�i✓z� -sTy� Z
�. <t �`�-�/,_
FEES ARE BASED ON $10.00 PER FIXT[JRE, EXCEPT WHERE NOTED. F'IXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV�. MINIMUM FEE
$35.SQ
BATH SINK(LAV FLOOR bRAINS 5HOWER WA'TER PIPING
$ATHTUB GA5 PIPING (NEED CITY LIC) � SWIM1vIING POOL ! WATER SOF7NEIt (S35)
� CLOTHES WASHER KITCHEN SINK � WATBR CLOSE� �BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATE (S35 T FOR IRRIGA7'ION
^ WATER METEIt � OTI�R
1SW11V�1 U1 }7J14WGS..�W `9#,J.VV A ypid.VV� � �R, :,. {
1
Num�r c�f fi�fiures �a $3S.QU x $3�.U� = � �
State Surcharge ' $ S.OU
fMINIMUM �40.001 Totai = $ % �
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing petmit and I acknowledge that the information above is compiete and accurate; that the work will be in
conformance with the ordinances and codes of the Gity of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and` work i not to start without a permit on site; that the work will be in accordance
with the approved plan in the case f ll rk hich re 're review and approval of s. )�
SIGNATURE OF APPLICANT ry��" _"� � PRINT NAME ��' �� r�u t�� DATE�
•n„�.�.:,.r nin.,n.+m�..�oot�.s—� n nw . "��k nnmc��%�9�
FOR
" City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 35432
763-572-3604
FAX: 763-502-4977
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