P - 45289Building
Inspections
763-572-3604
763-502-4977 FAX
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECIlVE 1-1-2011
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Permit No,ri�l
Received By:
Date Rec'
DATE "1 '"�I�! � YOUR E-MA1L ADDRESS i Gt�tit,t �t DI� %'� 1��'�S' lIG E� /i� ��G C. c"/�9
S[TE ADDRESS �F S�Y .i/'!) GIC� S l�' •/U. �'.. ��
THIS APPLICANT IS: ❑ OWNER I�CONTRACTOR
PROPERTY NAME:�. � i c�4� V �/'�c'�
OWNER/ ADDRESS:_ �p .� 7 Y „�dtc:�C s� /L� � CITY
TENANT pHONE: �F S� ��lK ' �/ yU�
TATE �! NZIP
CONTRACTOR NAME: `%?!K� ���h nJo � —� ���- � �/u r� b�rc�
SUBMIT A COPY OF STATE LICENSE �! ���U� K��� -� EXP DATE (� ` aG I�
YOUR STATE
LICENSE, BOND AND STATE BOND # C7S'�� 3j�Z EXP DATE
CERTIFICAT$ OF ADDRESS: ,�'�I % yv1 rF1�if,J� �d S� CtTY ,�IZc� kEOCC STATE iYJ/l1ZlP S�3?��'
INSUR.ANCE pHONE GJ„S�' �/O�✓';�i��I,3 FAX
PERMIT TYPE
TYPE OF WORK:
� SINGLE FAMILY
❑ NEW
❑ TWO FAMILY ❑ TOWNHOUSE
�7 REPLACEMENT
DETAILED DESCRIPTION OF W ORK % 'J'� �% � Pc� '� /1 �c� / u � �►?z Q •
T
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED.
$35.50.
BATH SINK/LAV FLOOR DRAINS
i� BATHTUB � GAS PIPING (NEED C[TY LIC)
CLOTHES WASHER KITCHEN SINK
DISHWASHEI2 LAUNDRY TRAY
FIXTURES: (]NDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
_ SHOWER
SWIMMING POOL
WATER CLOSET
WATER HEATER ($35)
WATER METER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UN'CIL PROCESSED
WATER PIPING
WATER SOFTNER ($35)
BACKFLOW PREV. ($]5)
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 appfication 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 e,S�f 1 wo which requires review and approval of plans. /
SIGNATURE OF APPLICANT �%/....�F ' .�h--- PRINT NAME /l7i K� ,�`G%1 �'1.S �' � DATE �I ' � � �� !
APPROVALINSPECTORSSIGNATURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977