P - 48245Building PLUMBING Permit No.�U Z,.►�� >`�
Inspections RESIDENTIAL APPLICATION Received By: �' �.M�
763-572-3604 CITY OF FRIDLEY �at��� ���
763-502-4977 FAX EFFECTIVE I-1-2011
DA'CE ���-��" � �� YOUR E-MAIL ADDRES3
SITE ADDRESS % .3 / .� %�' E> ! � S � � L
THIS APPLICANT 1S: ❑ OWNER �ONTRACTOR
PROPERTY NAME: [JG � -c �a, / , C
OWNER/ ADDRESS: CITY STATE ZIP
TENANT y —
PHONE: 7 � 3 -, � J �C "" `� �`''�l 1
CONTRACTOR NnME:_f'��vt'�r� j/'%v,,, I ��� P/v��CC C
SUBMIT A COPY OF STATE LICENSE # �/<i )�- t�+'t
YOUR STATE 4 P EXP DATE � Z— 3/—% Z
LICENSE, BOND AND STATE BOND # EXP DATE
CERTIFICATEOF ADDRESS: J Z�o i�G� /� C�rn.P /L+*i CiTY �c��,.n �°�;�,dJ STATF�� ZIPJJ�'f.��
INSURANCE
PHONE 7� 3-:�.?����) (� FAX 7� 3--�-f-3s-S�sil
PERMIT TYPE � SINGLE FAMILY �TWO FAMILY � TOWNHOUSE
TYPE OF WORK: � NEW � REPLACEMENT
DETAILED DESCR[PTION OF WORK �<� �T� h�i, 7�-� s� �� ��, �{;�., �
FEES ARE BASEDON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBGR OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOW ER WATER PIPING
BATHTUB GAS PtPING (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
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N,ueaib�e o���'IXtl�ie�'t�$7Q �� X $i{1 �€J � $
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�1����ro�'��tures@$15Q0� =.��$1��.0�0��—$���" .���-
Numl�er af,�res � �3S�0�T; � x $35.fl0 = $ �
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MINTi1�Ul�t,.$40.�}�� M���� Toial��, $, z,�-. ,, � ., �
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 ca e �j�ce ich.�e uires review and approval of pla .
SIGNATURE OF APPLICANT ���1 1��� PRINT NAME M+/c J� �C i DATE � 2- .3G-- , r
C' 7 v %
APPROVAL [NSPECTORS SI�NA�7 URE� DATE
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City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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