P - 45731Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECr,vE i-i-zo� i
DATE j'� " G�""' J/ YOUR E-MAIL ADDRESS
SITE ADDRESS �`�' i t� �j f` N S/ JV �L, �- k.-1 () (v
THTS APPLICANTIS: .�OWNER pCONTRACTOR
PROPERTY NAME: U Z,� (,�' (. �c z
OWNER/ ADDRESS: __ �p � � � 7� C� 5 T NiL
TENANT /'
PHONE: � iv �� � K'Lf ?j— Z � ! 'j
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
L[CENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
Permit No.: b ��-�� ��'�
Received By��
Dat���d� � � �� � � � � �
c.c.z.c�! k�� C� Lz. /�zJ U-► sr-� _
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/ `�
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C17Y F�� ��i�7 STATE�ffZIP � S �[ �L
STATE LICENSE # EXP DATE
STATE BOND # EXP aATE
ADDRESS: CITY
PHONE FAX
�SINGLE FAMILY ❑ TWO FAMILY O TOWNHOUSE
TYPE OF WORK: I� NEW
DETAILED DESCR[PTION OF WORK
�REPLACEMENT
STATE ZIP
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 DRAfNS SHOWER WATER PIPING
BATHTUB � GAS PIPING (NEED GTY LIC) SWIMMING POOL WATER SOFTNER ($35)
_CLOTHES WASHER � KITCHEN S1NK i WATER CLOSET BACKFLOW PREV. ($IS)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER {$35) FOR fRRIGATION
_ WATER METER � OTHER
TH[S IS A APPLiCAT10N FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a p(umbing permit and I acknowfedge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and y'des of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applica 'o ,rt�or a permi �nd work is not to start without a permit on site; that the work will be in acc rdance
with the approved plan in the c s all work i h,,re�1u_ire�s, review and appro al9 plans.
SIGNATURE OF APPLICANT � C.L� �% l'�"!��"'�` PR1NT NAME_ �I`r � I�Z�7 r DATE 10 ` r ��
APPROVAL INSPECTORS SI� A)RR �/,c_ 1 ru ':-ner�
City of Fridiey
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977