P - 46635Building PLUMBING Perrn�t rto.: I-t)"d`' �
Inspections RESIDENTIAL APPLICATION Received By:��
763-572-3604 CITY OF FRIDLEY D
763�SOZ-�i9%7 FAX EFFECTIVE I-1-201I ��'����
DA'I'E � YOUR AIL A RES3
SITE ADDRESS
THIS APPLICANT IS: � OWNER I�ONTRACTOR �
PROPERTY NAME:
OWNER/ pDDRESS: e��YJ') �P CITY STATE ZIP
TENANT punw�c. �i �t 4`7�_ �d/16C'
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
STATE LICENSE # ✓ EXP DATE
STATE BOND # EXP DA
ADDRESS:� 'S'�i �G�,�t �Z 71`[.
PHONE 7Ci ��J,�„ �+ �S�i_,S� FAX �
�SINGLE FAMILY O TWO FAMILY ❑ TOWNHOUSE �
TYPE OF WORK: � NEW �REPLACEMENT
DETAILED DESCR[PTION OF WORK 7✓
FEES ARE BASED ON SI0.00 PHR FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MIN(MUM FEE
835.50.
BATH SINKlLAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMMG POOL WATER SOFTNfiR ($35)
CLOTHES WASHER KITCHEN SlNK WATER CLOSET BACKFLOW PREV. (S15)
_ DISHWASHER � LAUNDRY TRAY _WATER HEATER ($35) FOR tRRIG TION
_ WATER METER _ OTHER�j¢ja.pl�Q.cjG
TH[S IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby appiy 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 1 understand this is
not a permit but only an applicatio pe ' d wo is not to start without a permit on site; that the work will be in accordance
with the approved plan in the c e wor 'c e ires review and a�pro/v�I plans.
SiGNANRE OF APPLICANT ��PRINT NANFG�i �� Ld e►' DATE (�
APPR(1VA1. iNSPF(TnRC CIGN IIRF IIeT�
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977