P - 46509Building
Inspections
763-572-3604
763-�02-4977 FAX
DATE � (I � ��
SITE ADDRES� __ '�Y �
THIS APPLICANT IS:
�I,�TIVIBIN�
RES��EN'�"�A� AP��.I��'�'I4N
��'�Y �F F��i�EY
EFFECTIVfi 1-1-2011
YOUR E-MAIL ADDRESS
--�, i _
❑ OWNER
PROPERTY Nq,�,tti �
OWNER/ ADDRESS:
TENANT
PHONE:
CONTRACTOR
� S
� CITY,
. �As�" � �P �vJ
CONTRACTOR NAME: �L ( V"W �'i'�i
SUBMIT A COPY OF STATE LICENSE #
YOUR STATE
LICENSE, BOND AND STATE BOND #
CERTIFICATE OF ADDRESS: �
INSURANCE pHONE �'' �i ''
�..'
PERMIT TYPE
TYPE OF WORK: o NEw
FAMILY ❑ TWO FAMILY
DETAILED DESCRIPTION OF WORK
�REPLACEMENT
FAX
❑ TOWNHOUSE
Permit No.:_
Received B:
R���e�"�
EXP DATE
EXP DATE
S�'ATE�ZI r � �
FEES ARE BASED ON $] 0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER _ WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL _ WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATERCLOSET _BACKFLOW PREV. ($15)
DISHWASHER LAUNDRY TRAY =WATER HEATER ($35) FOR IRRIGATION
— WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID 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 codesraf the Ci f Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a perm�t w rk is not to start without a permit on site; that the wark will be in accordance
with the approved plan in t�'e f a ark wh� re ires review and appr � 1�Q pl /
SIGNATURE OF APPLICANT `� R1NT NAME� l��� ��1�� DATE /I i
APPROVAL INSPECTORS SIGNATURE DATE
City of Fridley
B ilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432 �
763-572-3604
FAX: 763-502-4977