P - 48190Building
Inspections
763-572-3604
763-502-4977 FAX
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTTVE 1-1-2012
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Permit No.:
Received By:
Date Rec'd:
DATE � �� D..� �� YOUR E-MAIL ADDRESS /� ��.r e rn a►� � Gn m va s-r, /(/ �'7'
SITEADDRESS ��' f] �% � �t�L� �VE
THIS APPLICANT IS: ❑ OWNER �'CONTRACTOR
PROPERTY
OWNER/
TENANT
u
ADDRESS: 3�t � Le �'Y� l: V� /V E CITY
PHONE:
<<J�E
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CONTRACTOR NAME: l�0 �I � S
SUBMIT A COPY OF STATE LICENSE # O S-�'i $ p I F� ✓�
YOUR STATE EXP DATE /� 3/ ��
LICENSE, BOND AND STATE BOND # �z c� q 3� �. �►- EXP DATE � 3� � 3
CERTIFICATE OF ADDRESS:17 �{ a U � 6 Gt /l NA Si N W �IT.1, Q�p M S C-�/ STATI�'1 li ZIP
INSURANCE PHONE xp � ' C.F�-f I -^ �a� �I FAX 7 � .3 ' y �'i I ' � .`�- � %
PERMIT TYPE
TYPE OF WORK:
�:SINGLE FAMILY
O NEW
❑ TWO FAMILY ❑ TOWNHOUSE
�(REPLACEMENT
_--
DETAILED DESCRIPTION OF WORK %�,�(�LP�
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 GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
_ CLOTHES WASHER _ KITCHEN SINK WATER CLOSET 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 the case of all work which quites iew and approval Qf p�l [�
SIGNATURE OF APPLICANT �f� PRINT NAME�(.,�j�/ �> RAS�( U SDATE (� �����-
APPROVAL INSPECTORS SIGNATiJRF, / .1.� / il „�-�
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977