P - 47789Building ������N�
Inspections �, 5��, N�,�� A�����,A�,��N
763-572-3604 c��,,� O� ������
763-502-4977 FAX
, _ EFFECTTVE 1-1-2011
DATE 1�/ iS / ( �
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
_ PERMIT TYPE
TYPE OF WORK:
❑ OWNER g(
/'
NAME: �
ADDRESS: n
PHONE:
NAME: GI� �
STATE LICENSE #
STATEBOND#
ADDRESS: �� � �
PHONE � �%i - �i
� SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
YOUR E-MAIL ADDRESS
❑ TWO FAMILY
9
�7 REPLACEMENT
V�=�--�
CITY
Permit No.
Received B
STA
, �:�
��o
EXP DATE
EXP DATE
CITY_ s STaATE�_ZIP_ � ��-
FAX � "�t✓�— 2�/I�X
❑ TOWNHOUSE
FEES ARE BASED ON $10.00 PER FIX1'URE, EXCEPT WHERE AjOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
_BATHSINK/i,AV _FLOORDRAINS SHOWER
_ BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL — WATERPIPING
_ CLOTHES WASHER KITCHEN SINK — _. WATER SOFTNER ($35)
_ DISHWASHER — WATER CLOSET BACKFLOW PREV. ($IS)
_ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
_ WATER METER OTHER
rs� � � �, e� ,r�. � _ _
_ __. . .. .... ,, v,: ��,,:
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 co e 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 pe it and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the c�����v/ worl quires review and approva �of . lans.
SIGNATURE OF APPLICANT `' PRINT NAME ;X�/L� C�G�.�aiC- I�Qi,�:r/�
APPROVAL INSPECTORS SIGNATIJRE DATE (�
City oi �ridley
�uilding Inspections Department
6431 University Avenue NE, Fridley; NIN �5432
763-572-3604
FAX: 763-502-4977