P - 46262Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � I �C
SITE ADDRESS a
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A CQPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
PLUMBING Permit r1o.:` ' �
RESIDENTIAL APPLICATION Received By: .n�
CITY OF FRIDLEY vat��et�d;,J��_� �
EFFECT[VE I-I-2011
YOURE-MAILADDRESS ^��G�l��� c� C�A✓'?EUS� /1��
> � Lt�'ottii � �C
❑ OWNER
a't''� /�/�'o2e/�
t ( S'� Aii%. � crrY,
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STATE LICENSE # � y�// /
STATE BOND # L OS�v.� S
ADDRESS: /dt.S�`I %S¢I� I _ � CITY_
PHONE �6�3- y93 -3-��,�1 FAX
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TYPE OF WORK: I� NEW
FAMILY ❑ TWO FAMILY O TOWNHOUSE
DETAILED DESCRIPTION OF WORK
p�R�PLACEMENT
C[
STATE /' Y�ZIP
M /'
EXP ATE 3 /'--
EXP DATE
G�io �C_. STATE /y1 �✓ ZIP S�/ 9
FEES ARE BASED ON $16.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV _FLOOR DRAMS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL ^ WATER SOFTNER (S35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET ^ BACKFLOW PREV. (S15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LINTIL 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 the ca e o� al}l '�o��..0 which r uires review and approval ofp la�i '
SIGNATURE OF APPLICANT ��V��'��--�--�� PRINT NAME R'�/�C �f"���� Ztw�I�� DATE �/�� �f
APPROVALINSPECTORSSI ATURE � DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977