P - 48118Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE i-1-2011
DATE � � Cv
SITE ADDRESS �
T'HIS APPLICANT 15:
PROPERTY
OWNER/
TENANT
Permit No.:
Received B • ' �
Dat���d: ��
YOUR E-MAIL ADDRESS 1 Cv✓`7 K C I S b''� � l=- C S� «5�� "� t-�
�C�l �tr
❑ OWNER �CONTRACTOR
NAME: C f c�m.rr t I�15 "`
ADDRESS: L O �'�'^ �' ��' CITY rr
PHONE: �L �' S 7I " � q d °�
TA
CONTRACTOR Np1�t�: 'c✓� a�sa�t P/h Tr.�L.
SUBMIT A COPY OF STATE LICENSE # p S"qDO 3 � u'� EXP DATB / a( ��l � a � 1 0�
YOURSTATE
LICENSE, BOND AND STATE BOND # T�/ $ $�i l EXP DATE I,�l 3/ � 20 ��
CERTIFICATEOF ADDRESS: I76�13 ttrq,�vc S? N� CITY STATEP�� ZIP S�S3?�`'
INSURANCE pHONE ��� ��I7 9 9 g% FAX JL'� `��� �? g� ,
PERMIT TYPE
TYPE OF WORK:
�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
Q�REPLACEMENT
❑ TOWNHOUSE
�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELAW). MINIMUM FEE
$35.50.
BATH SINKJLAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPtNG (NEED CITY LIC) SWIMMING POOL WATER SOFT'NER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. (S15)
D13HWASHER _ LAUNDRY TRAY �WA7'ER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VAUD 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 th�eS� e of all ' h requires review and approv f plans. /
SIGNATURE OF APPLICANT /-�f PRINT NAME �V✓�1 � r-�S[S vj� DATE �(v '� �
APPROVALINSPECTORSSIGNAT�E DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977