P - 84241Building PLUIY�ING � Permit No. t� ��a ��' � S�
Inspections RESIDENTIAL APPLICATION xeceived s.
763-572-3604 CITY OF FRIDLEY ����}� e�Q1
763-502-4977 FAX EFFECTIVE I-1-2012
DATE �„g YOUR �MAIL ADDRESS � �
STTE ADDRESS `i 1 � �I. �' S�k'` i Z.
THIS APPLICANT IS: '� OWNER �CONTRACTOR
PROPERTY NAME: `�Q� /'1�(+JV� j�}o..rtd o,c.�
OWNER/ ADDRESS: '� ,3 � �i f�► �L(i1./` 'b �" ^% �'s CITY F=y�{,1,.��y STATE 7a%%iIILIP��
TENANT pHOI+IE: �i lZ -$`S �! ^ Z°I,`� O
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # EXP DATE
YOUR STATE
LICENSE, BOND AND STATE BOND # E3� DATE
CERTIFICATE OF pDDRESS: CITY STATE ZIP
INSURANCE pHONE FAX
PERMIT TYPE � SINGLE FAMILY O TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � �W � �PLACEMENT
DETAILED DESCRIPTION OF WORK (�,Y! I.K4.�C_ � �/ca���� e�,.��.� �{��� *'r�
1.�s�..,�.�.►.�- i3��c�,
FEES ARE BASID ON $10.00 PETi FIX'I'IJRE, EXCEPT WHIItE NOTID. FIX"I'[JRES: (INDICATE TOTAL NUMBER OF EAGH BELOV4�. IvIiNATUh+I FEE
$35.50.
� BATH SINK/i.AV X� FLOOR DRAINS � SHOWER � WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) ' SWIMIvIING POOL WATER SOFTNER ($35)
CLOTHF.S WASHER KITCiIEN SINK WATER CLOSEC BACKFLOW PREV. ($15)
DISHWASHER _ LAUNDRY TRAY WATER HEATER (S35) FOR IIiRIGATION
WATER METER OTFIIIt
Number Of fxtureS Q$10.00 � X� 10.1?4 =� �% O�
�iumber offixtures @ $15.Od x 515:00 = S
Number of fi�ures Q�35.fl0 x$35:04 = S
State Surcharge $ S.OQ
S40.00 Tota1= � �4g �
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 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; tl�at the work will be in accordance
with the approved plan in t,�c se of �il work which requires review and approval ofP.la�ns.���"�� �
SIGNATURE OF APPLICANT �?L'%�t'/(%L�� PRINT NAME `Tb1h 1�/WE w y�' DATE �� � J � Z-
APPROVAL INSPECTORS SIGNATURE DATE
PLEASE NO'I'E: S�PARATE PERMITS ARE i:1IRED FOR BIJILDING EI,�CTRICAL A�i'D MF.�HANiCAi:'9f��C
City of Fridley
�uilding Inspections Department
b431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977