P - 60357Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �. / `'[
SITE ADDRESS `
THIS APPLICANT IS
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MAIL ADDRESS J 1 K-�-
❑ OWNER '�ONTRACTOR
PROPERTY NAME:�rn��.� G,�{p�� �Rp
OWNER/ ADDRESS:
TENANT
PHONE:
0
Permit No:
� - - � : ��,; i
�.�, �.'� �+ �� ; 1.
ATE ZIP
CONTRACTOR NAME: � i(� h-i ✓3' -('t�_ R.� �L1� �i..{ �4i.i i c�t� (,� �-
SUBMIT A COPY OF STATE LICENSE #_� '�j q O� � 'P U�/\ EXP DATE �� I 31
YOUR STATE � � �
LICENSE, BOND AND STATE BOND # ��(D �--( �."� �'� ExP DATE t z 13 i� � 3
CERTIFICATE OF ADDRESS: S�le� �n_-r�..�p S'�' �l � CITY ✓Vi P� 5 STATE�_ZIP 'J L
INSURANCE pHONE�,tQ 3 ^-'~( S�' � � � � �� � FAX � (Q � -� $ �" � Si0 �
PERII�IIT TYPE
TYPE OF WORK:
�SINGLE FAMILY
❑ NEW
❑ TWO FAMILY ❑ TOWNHOUSE
4'�tEPLACEMENT
DETAILEDDESCRIPTIONOF WORK ��.�pP�� , w��rt �- tlwr .��� S7�D /��4st�
�j �� v-�c� mnE �� 1-�.o s� !� � 13 � S
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXNRES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL
� CLOTHES WASHER KITCHEN SINK WATER CLOSET
_ D[SHWASHER _ LAUNDRY TRAY WATER HEATER($35)
_ WATER METER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
WATER PIPING
WATER SOFTNER ($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 wark 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 case all wor w i requires • and approval of plans.
SIGNATURE OF APPLICA _...� PRINT NAME� +4�vk� j � rc� p��-h� TE 'z' �
C�
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977