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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