P - 60330Building
Inspections
763-572-3604
763-502-4977 FAX
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
_ EFFECTIVE 1-1-2012
Permit No `
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DATE � Q{�1 � CD _ ZUI Z . YOURE-MAILADDRE3S 1f1i�GC�',�UbO`(`C Cr�Y�•C�VYI
SITE ADDRESS _ � 3�J ��� U.�C�� i�1C
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
OWNER ❑CONTRACTOR
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Y�
ADDRESS: l3?v �jlp �h U.�� �i� CITY
PHONE: � IG 3' S(� �. - �-I qS
STATE LICENSE #_
STATE BOND #! _
ADDRESS:
PHONE
�SINGLE FAMILY
❑ NEW
DETAII.ED DESCRTPTION OF WORjC
❑ TWO FAMILY
�REPLACEMENT
Ca
� M�z�r 5S' 3
EXP DATE
EXP DATE
� Y STATE ZIP
FAX
❑ TOWNHOUSE
iin �Uo,.V-hr�o�
`J11c���r
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)
_ CLATFIES WASHER _ KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATTON
_ WATER METEIt 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 a all wprl ic e uires review and a roval of lans. ��� b� Z� �.L
SIGNATURE OF APPLICAN�__�,��.I 7�t� � q4�1 l riJ pRIIdT NAME M t.1'pZC1b��Y� � CO�-+%J`DATE �P
APPROVAL IIVSPECTORS SIGNA E CJ r..,..,
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977