P - 42834Building PLUMBING Perrnit Ivo . �'+
Inspections RESIDENTIAL APPLICATION g,, i� d
763-572-3604 �1,� � ����'�
763-502-4977 FAX CITY OF FRIDLEY ate Rec d:
EFFECTIVE 1-1-2011
DATE �� �J" l YOURE-MAILADDRESS lAI�IZ��i2 �QYYV(jUQ.,l'�CXC.�CA'�PItM'��C+lc, •Y1��'
SITE ADDRESS � 5�� Q�Q� (' 1�%G., tS
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY NpME: e
OWNER/ ADDRESS: S0.Yy�2, AS cJ0 o ii-�. CITY �i't GL I.G u STATE�ZIP� �
TENANT
PHONE: ��03 � ��� I ' �i'�I S �[
CONTRACTOR NAME: -CerY��,,� C� �-e.f- c. e� � o-^
SUBMIT A COPY OF STATE LICENSE # OI,� IG �-I � f" M EXP DATE I a. - 3 �-(
YOUR STATE `�-� �
LICENSE, BOND AND STATE BOND # �'n �L �.2 EXP DATE
CERTIFICATE OF ADDRESS: 5u � �'IYi�-N S� CITY Ar� a�c,_ STATE ZIP� 3 a3
INSURANCE pHONE `7�03 - 5� a - ���, o FAX � �� " �' ��9
PERMIT TYPE �SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW �kEPLACEMENT
DETAILED DESCRIPTION OF WORK
FEES ARE BASED ON $10.00 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 ($35)
CLOTHES WASHER KITCHEN SINK � WATER CLOSET BACKFLOW PREV. ($IS)
DISHWASHER _ LAUNDRY TRAY ¢WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
�� _� z • � �� °� _ . ,° � � � � � �� � e � �
'���-c���7�"e� � �S�t.�B "� ��13.E� = � • � �� �� � � �
-��� , r�`�
�T��` c�f�i�'tures r�i $t5:�ff x � 1 � (�Q = $,�,,,�, � � �
x
�+Tumbercr�'f�res {u7 9�35.� �� � a� ��.�fM � $� �' �' F
.�°-4»r.: �-;.�c:.� ._ .;:,.,,_ _ S 5_0� .._.....-._.i.� �� --
MIN�MUM �Q4.4Q Total = $ ` 13 • G� '
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 wark will be in
conformance with the ordinances and codes of the City of Fridley with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and work is not start w' hout a permit on site; that the work will be in accordance
with the approved plan in the r uires v� w and a�Qyal of , lans. +
SIGNATURE OF APPLICANT RINT NA '�-✓ SY' DATE 1 b' '� j
APPROVALINSPECTORS IGN URE DATE
PLEA:SE NC�'��: SEFARATE F�RI�IITS AI�.E �? �C1R I3LTILI)�NG EL�i'TkICA� Ai�tQ:l'u�EC '� �A%,. �. _;
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
'163-572-3604
FAX: 763-502-4977