P - 42243Building
Inspections
763-572-3604
763-502-4977 FAX
DATE 1� V i'� l li
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMTT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
P��T1��3�N�
R�S�DENTIAL �PPI.��A'�'I�►1°�T
CITY �F FR..IDLEY
EFFECTI V E 7-1-2010
YOUR E-MAIL ADDRESS
❑ OWNER
NAME: [��� � �VdL�/I i'a v,� _ _
ADDRESS: (II�-I Q'� � IYL— /��� CITY.
PHONE: �'�•%�.� IY�I ��
Permit No.`
Received By:� � �.�'
������:L ����
�
STATE LICENSE # ' J EXP DATE
STATE BOND � EXP DATE
ADDRESS: D Yb� �t ,�?i� CITY /�'I I'fM STAT ZIP�S�!2
PHONE FAX
"�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVI�. MINIMLTM FEE
$35.50.
BATH SINKiLAV FLOORDRAINS SHOWER WATERPIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER lKTI'CHEN SINK WATERCLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY =WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
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 permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in t c o� Il wor ��y requires review and appro 10. pl
SIGNATURE OF APPLICANT ���� :f"'V PItINT NAME I -- DATE �l���10
APPROVAL INSPECTOILS SIGNATURE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977