P - 60270Building PLUMBING Permit No.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY vate Rec'd: �'.�
763-502-4977 FAX EFFECTIVE 7-I-2010
DATE�Q�
SITE ADDRESS _
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
YOUR �MAIL ADDRESS �ls1 �
❑ OWNER
NAME:
aDDxESS: �5i
K
PHONE: �l� 3 -
STATE LICENSE # Cl t
STATE BOND # C?�'1 i I�
ADDRESS:��,� �/��Gt�✓� CITY_
PHONE �I q ) ` J /O'– ���� FAX
SINGLE FAMILY
� NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
REPLACEMENT
'G� e.�. ��� u �
�
TATL��II ZIP�3 �
EXP DATE l l Itt"
_ EXP DATE
IC� STATE ZIP
'� '�'. c��'�'i
FEES ARE BASED ON $10.00 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 ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($IS)
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 ork ' not to start without a permit on site; that the work will be in accordance
with the approved plan in the c e of all which req ir review and appr val of 1�
SIGNATURE OF APPLICANT '�ih.- PRINT AME� �'L 1'� I��SJW%��� DATE �
APPROVAL INSPECTORS SIGNATURE
`" City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 �� �q �
FAX: 763-502-4977 G