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Building PLUMBING Permit No.:
Inspections RESIDENTIAL APPLICATION Received B.
763-572-3604 CITY 4F FRIDLEY Date Rec'd;l� � �
763-502-4977 FAX EFFECTiv� i-i-2ar i
DATE ��a.7I �/
YOUR E-MAIL ADDRESS �T �15£I /� . C� A-+_ � C i9 '��
S1TE ADDRESS -T S I S %ii3�E S"T- 1vE __--_ -
TMS APPLICANT [S: ❑ U��v'NER �CON"1'RACTOR
PROPERTY N�,s,q�: 1-A., N t ti(� c
OWNER/ .4DDRESS: �7 S � � P_ � /� �' .t/e CITY ��a /rZ S7 ATE Al�ziP tSl7u�-
TENANT
PH01�IE' � O .'%
CONTRACTOR NAME: �t c. �-�ecN�a.-�i c�a �Jr`Qu�c�r S
SI;BMIT A COPY OF gXp DATE � 3! /2-
YOI: R STATE STATE LiCEKSE N �(c �I 31 n I P►�
[�/3(� rP�i EXP D�1TE _[ Z�3r Ii �
LICENSE, SO?1D ANll STATE BOND # Co — �'/ STATE �cJ Z[P SS�2
CERTIFICATE OF ppDRESS: �I7l� �cc�Qc2� SY t°�' C1TY �ta.�r�cC/�o - .��--
INSURANCE PHO1�E �__�(e�Z3!'�� 0�1�e--- FAX "7(c���95 -Olcs`/ _
PERMIT TYPE
TYPE OF WORK:
❑ SINf,LE FAMiLY
Ll NEW
❑'1'WOFA�4ILY �TOWNHOUSE
� REPI.ACEMENT
DETA(LEDDESCRIPTION OF WORK ��P���rC ERCrf ��4n -�' ���'-'� �'"'��'"�����
___��LI�-4-----��T�-- - - �
FEES ARE SASED Oh $10.00 PGR FIXTURE, EXCEPT WHERE NOTED.
$�S.SO.
BA'i'N S►NKILAV FLQOR DRAINS
� DATNTUB � GAS PIPING (NEED CSTY L[C)
�CLOTF�ES WASHER KITCNEN SWK
� �1SHWASHER _ LAUNDRY TRAY
Number of fixtures Q �►U•00
Number of fixtures @$ I 5.0a
Number of fixtures @ $35.0�
State Surcharge
M
x $10.00 = $
x$15.fl0=S
x $35.00 = $
S 5.00
Tatal = $ �id
FIXTURGS: (INDICATE TOTAL VLtMBER OF EACH 8EL0�'). MINIMUM FCE
SFIOWER
� SW[MMING PQOL
� WATER CLOSET
WATER HEATER (S35)
� WATER METER
� WATER PIP[1:G
WATER SOF'iPiER ($35)
9ACKFLOW PREV. (�75)
J FOR IRRIGATION
OT}iER
THIS IS AN APPL[CAT10N FOR A YERMIT-NOT VA[.ID UVTIL PROCESSED
[ hereby apply for a plumbing permit and [ acknowledge that the information above is complete and accurate; Ehat the work will be in
conformance with the ordinances and codes of the City of Fridley a with the Minnesota Construction Codes; that 1 understand this is
not a pertnit bul only an application for a perrnit and wos i not start widiout a pertrtit on site; that the work wi�l be in accordance
with the approved plan in th e of a!1 work which requires vi ��d ��provaso ; p,lans. R' DATG��
SIGNATURE OF APPLICANT �� pATE
APPR04'AL 1NSPECTORS SI . ATl'RE
PLEASE NOTE: SEPARATE PfiRM[TS AkE REQ U1LDING, ELECTRICAL AND MECHAN7CAL WORK
City of Fridley
Building Inspectians De�artment
6431 University Avenue NE, Fridley, MN 55432
763-572-3b04
FAX: 763-502-4977
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