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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