P - 481230
Building PLUMBING Permit No:: �
Inspections RESIDENTIAL APPLICATION Received By: �
763-572-3604 CITY OF FRIDLEY Date Rec'ct: � �
763-502-4977 FAX EFFECTIVE 1-I-201 I �� . ..
DA7'E ''pL`% �
S[TE ADDRESS
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
❑ OWNER
�- c-� � i —
E-M A
r' /
ITY
CONTRACTOR NAME: /°� C�!/%Z%%F
SUBMIT A COPY OF STATE LICENSE # $" -
YOUR STATE
LICENSE, BOND AND STATE BOND #
CERTIFICATE OF pDDRESS:� ! t�' S!<Cy/t7�-- _ C�TY
INSURANCE pHONE �5��-��^a'9D� �1++Y�
PERMIT TYPE O INGLE FAMILY O TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW LACEMENT
DETAILED DESCRIPTION OF WORK
Cy
�
EXP DATE � ���v�Ol �
�EXP ATE ��[�2 3I ' aO / I
_STATE�1 P�
�lv? "av?/ � C/'hi G 9
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BEIAW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
�'BATHNB GAS PIPING (NEED CITY LiC) SWiMMING POOL WATER SOFTNER ($35}
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($75)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRR]GATION
WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing pe tt d I acknowledg t the information above is complete and accurate; that the work will be in
conformance with the ordinance a codes of the i Fridley and with the Minnesota ConstrucC' n Codes; that I understand this is
not a permit but only 'c for a permi rk is not to start witho a permit o ite• at the work will be in accordance
with the approved pl in the h' view and appr/ �val f plans.�
SIGNATURE OF APPLI PRINT NAME V /(/ DATE��^� 5����
APPROVALINSPECTORSSIGNATU nATF
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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