P - 48617Building PLUMBING PermitNo`���i;i�'/1;��;�� '�
Inspections RESIDENTIAL APPLICATION Received By: '�� 1�
763-572-3604 CITY OF FRIDLEY Dat�� °�c� �, � n tt ���i �
763-502-4977 FAX EFFECTTVE �-�-2oiz t��Cl,'U �°�-r„-�--'� �'
DATE 5� `�� � Z��Z YOUR E-MAIL ADDRESS ��1��� �S lO/��`/" C��/G . G�L�!'1�I
SITEADDRESS / 7 7Z � �'o¢�� �'� ��� G/�'s/�c`Z-c��^��/�j ,SS�3L
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
1NSURANCE
NAME GCjL.(/GLG `'U�t �'-2
ADDRESS: �.3%Z-G>¢� �wy� CITY �/Pi�c�cN STATF��ZIP SS-�%�
PHONE: �'� 3"` i�2 ' 2 2�? j
STATE LICfiNSE # C G� 5� �' 3 EXP DATE / Z-�/' Z L` /3
STATE BOND �S EXP DATE
ADDRESS: Z C'�f� 5 li�l1¢st/o:�Z � �'J CITY �,A'C�C S/OiL'- STATE�ZIP S�'���
PHONE lr /2'� �G � " �%GG> FAX
PERMIT TYPE I ��GLE FAMILY
TYPE OF WORK: I �NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
❑ REPLACEMENT
. /, -
❑ TOWNHOUSE
�'ti ;
���
FEES ARE BASED ON $]0.00 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 GA3 PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35) � �?%
� CLOi'f�S WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($1���
DISHWASHER LALTNDRY TR.AY WATER HEATER ($35) FOR IRRIGATION `
— — — WATER METER � OTHER •.h - r?c,,c i'
,,T,....�...r .: F�...,._,.., �ri � 7 n nri ., si n nn ;- s
ltiiuniber of fi�:tu�es ,r $15.C�� � S
?'vrusnt�ez- oifixtures a> $;S.DO x �
C+�to' �,.,-,-h.�r�r� .
(���i�i�,�''��.1'i�`� �i�.�}Q} �. . �� �Dt�11 �". "'"„�, ,, ✓ r.,"""-
T'H1S IS AN APPLICATI�N FOR A PERMIT-NOT VALID UN77L 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 Consmzction Codes; that I understand this is
not a permit but only an application for a permit nd work is not to start without a permit on site; that the work will be in accordance
with the approved plan in th�. �a e of all o quires review and approval o� plans.
SIGNANREOFAPPLICANT .,,!�;�-C,,�� PRINTNAME �/�>.5�,�`}-`�%�f�S' DATE 3'��"��L
APPROVAL INSPECTORS SI T DATE
City of Fridley
Building Inspections Department
6431 Universiry Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977