P - 35048Building PLUMBING Permit No.:��� /J
Inspections RESIDENTIAL APPLICATION Received By: �
763-572-3604 CITY OF FRIDLEY Da '
763-502-4977 FAX EFFEC7TVE 1-1-2011 �„�� ��
DATE L YOURE-MAILADDRESS ��let/ LJD�I� ).A��6.M/f�L.�Q�t/�
SITEADDRESS �, Z�O J�}�� (���j
THIS APPLICANT IS: ❑ OWNER ,�CONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
NAME: l P.�'r"i�
ADDRESS: G 2—
PHONE:
CITY �/� �1.� �/ STATh!-1� ZIP��
NAME: �C�C� W IL� ',V�s
STATE LICENSE # S�� S L—(�!� EXP DATE P'� f /'L
3TATE BOND # R� I o 5 t 6�- 6 g EXP DATE ��'- S( �
ADDRESS: L{Q 3S 1 55�� �-rU ^�(i'% CITY /Q�'�5�� STATE !y/� Z1P Jr�3�17.
PHONE (0(2— ���QU FAX
1�SINGLE FAMILY
❑ NEW
D TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
DETAILED DESCRIPTION OF WORK � n(�� �.�5 L �.N� r� ���f S /vF,NG�
--7-
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED.
$35.50.
BATH SINKILAV FLOOR DRAINS
BATHNB � GAS PIPING (NEED CITY L1C)
CLOTHES WASHER KITCNEN SINK
_ DISHWASHER _ LAUNDRY TRAY
FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MiNIMUM FEE
SHOWER
SWIMMING POOL
WATER CLOSET
WATER HEATER ($35)
WATER METER
THIS IS AN APPL1CA710N FOR A PERMIT-NOT VALID UNTIL PROCESSED
WATER PIPING
WATER SOF7TJER ($35)
BACKFLOW PREV. ($15)
FOR IRRIGATION
_ OTHER
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 c of al woI� 1c requires review and approva of plans., �
SIGNATURE OF APPLICANT �c��--�J PRINT NAME ��u..� w� 1� DATE �'� � I�
APPROVAL INSPECTORS SIGNATURE �DATE
City of Fridley
Building Inspections Departmer►t
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977