P - 44561Building
Inspections
763-572-3604
763-502-4977 FAX
DATE D`—��"� ��
SITE ADDRESS -j=
THIS APPLiCANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MAIL ADDRESS
7 - `' G'1 �, �- �.'� _ .c,
D;OWNER �CONTRACTOR
NAME: '� v � !� %C�i(/.�I
ADDRESS: � �� (� Y �J� '� L
PHONE: _ � � 3 '" �o �'V ^I — �J I �O 3
Permit No.:� � � � � � ��
Received By:m�'
°��'�'�-e.��.$�l �
� r. c� � t' �a STATE�ZIP 53�-f3Z
NAME:
STATE LICENSE #
STATE BOND #
ADDRESS: CITY
PHONE
Q�SINGLE FAMILY
❑ NEW
� TWO FAMILY
� REPLACEMENT
FAX
0 TOWNHOUSE •
DETAILED DESCRIPTION OF WORK v o. \ � e. J e p iac c rnQ.r��G
�
EXP DATE
EXP DATE
TE ZIP
FEES ARE BASED ON $f0.00 PER F{XTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). M1N►MUM FEE
$35.50.
_ BATH SINK/LAV FLOOR DRA(NS SHOWER �WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
rCLOTHES WASHER K(TCHEN SINK WATERCLOSET BACKFLOW PREV.($IS)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR lRRIGATION
_ WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID IJNTIL PROCESSED
I hereby apply for a pfumbing permit and I acknowiedge 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 1 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 o�all �v�`r.k��wh�ct�°res}u�'es r�uaew and approyal of plans. , //
SIGNATURE OF APPLICANT_..---- �� t`-=---- '" PRINT NAME J� � c. : V��� �/lG� �.�/��c ( G�' "—��� I�
APPROVAL INSPECTORS S�4�IA7'URE T— nnTF
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977