P - 45478Building PLUMBING Permit No.:�� I��Q' I�°�
Inspections RESIDENTIAL APPLICATION Received By:.� T
763-572-3604 CITY OF FRIDLEY ��1:1�- �. �- ����
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE � �� � � �� I �
SITE ADDRESS ca1�
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
YOUR E-MA[L ADDRESS (',QF�TA�
'tu pL...Ac_ �,
❑ OWNER r�LONTRACTOR
NAME: 1..�4�' (Ll
, .,
ADDRESS:� '�� L., CITY �;'� j 1'Z��STAT�ZIP.
PHONE: �D ( ca� �"' R 1 c�-' � �� R LA �-�'Z ��
NAME: i.!-lY 1 I�1(_. �`'t_UMK jN ({� L �...C,.,. �P:
STATE LICENSE # r+
STATE BOND # q� I �
ADDRESS: 3� fl` T � CITY I
PHONE -�'L�j a '. �� �� I �-�T- FAX
FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
❑ REPLACEMENT
EXP DATE I
EXP DATE I
" r�w
ATE �� ZIP��
DETAILED DESCRIPTION OF WORK (N`�T'l-�i�... �,�'Lc,.r� �,-6\J�lV��., �,p (L, � V�'i�� [s�� 0/�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELO W}. 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 [RRIGATION
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,th ase �rk which requires review and appro a] of an+� . + 7
SIGNATURE OF APPLICANT��c -,y'1,�1,��c+—�,_ PRINT NAME �,9C�i.A -,.]u ta�/5}i'./ DATE �—' C I" I I
APPROVAL INSPECTORS SIG TU DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977