P - 35176�ng PLUMBING
I ions RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE � � 1p - l �
SITE ADDRESS 10 �O �p� � h � V� 1\
THIS APPLICANT IS: ❑ OWNER L�J1
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
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YOUR E-MAIL ADDRESS
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ADDRESS:,� O (�O �1� { � �11�- � �% CITY �'� ,
PHONE: '�(p3 — � % Z ` 2- 3 � �
NAME: L11n v� �' G�J' �trc,�s \ Y� �•
STATE LICENSE #� fQ �- 1� �" P I�
STATE BOND #'JrS � O-1 'rJ c3 p
ADDRESS: 1 19S l�, `o� �t'. � ��CITY �
PHONE 1�J Z� �I4 2- ' 1(i7�t� FAX G
TYPE OF WORK: I� NEW
FAMILY ❑ TWO FAMILY
0
DETAILED DESCRIPTION OF WORK
Permit No.:
Received By:
D�,� t���
� n nS-�-ar , c..o r�
ATE�IP �J s �'I 3 Z
EXP DATE I 2-- 3�� Z� I Z
EXP DATE I� l��-0 � Z-
�\ fG►+1YIe- STATE MN ZIP SS3�{y
52-9�1 - 5�'23
� TOWNHOUSE
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MMIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
,Q��, _ KITCHEN SINK _ WATER CLOSET BACKFLOW PREV. ($15)
�� �` _ LAUNDRY TRAY WATER HEATER ($35) ^ FOR IRRIGATION
-�° � WATER METER OTHER
THIS [S AN APPLICATION FOR A PERMIT-NOT VAL[D 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 an . es of t City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application fo e mi an ork is not to start without a permit on site; that the work will be in accordance
with the approved plan in th e ' es eview and app�jv,,al of pl s _L' j� , �
SIGNATURE OF APPLICANT INT NAME�' `�'Q� �� C'��UX� C.�1eDAT � _
APPROVAL INSPECTORS SIGNATURE DATE ,
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977