P - 41787Building P��J1��3IN�
Inspections RESID�N�IAr, rL API��ICA�'ION
763-572-3604 CITY OF FRIDL�Y
763-502-4977 FAX F.F��cTivE �-i-zo>>
DATE ✓� '� � �j
SITE ADDRESS �!L} � 17{'i�IL�'�/W
THIS APPLICANT IS: ❑ OVJNER
PROPERTY NpME: � L
OWNER/ nDD�ss: �dS 2
TENANT �
PHONE:
CONTRACTOR NAME: K(VLi/V
SUBMIT A COPY OF
YOUR STATE STATE LICENSE #_
LICENSE, BOND AND STATE BOND #_
CERTIFICATE OF ADDRESS: �iC�
INSURANCE pHONE i'� ,3.-
PERMIT TYPE �/SINGLE FAMILY
TYPE OF WORK: � NEW
DETAILED DESCRIPTION OF WORK
YOUR E-MAIL ADDRESS
��
�- �n� .
❑ TWO FAMILY
�REPLACEMENT
Permit No.: � —�
Received By:
Date Rec'd: �/ �
CITY TVt�I�(M' STAT�/�YVZIP��c�
FAX
❑ TOWNHOUSE
EXP DATE
EXP DATE
STATE ZIP 5 � 2
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). NIINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHNB GAS PIPING (NEED CITY LIC) SWIMMING POOL J WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTf�R
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 p �t an ork is not to start without a permit on site; that the work will be in accordance
with the approved plan in the of ail wo k whic r uires review and approva _of lan
SIGNATURE OF APPLICANT �� P NAME ;��G � DATE � I
APPROVAL INSPECTORSSIGNATURE { DATE
0
City of Fridley
Building Inspections Department.
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977