P - 84391Building
Inspections
763-572-36U4
763-502-4977 FAX
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THIS APPLICANf ISc
From: unknown Page: 1/3 Date: 10l95/201211:39:09 AM
PLUMBING Permit No.: 1Z�I ��
RESIDENTIAL APPLICATION xeceivea By:1'Y��
CITY UF FRIDLEY Dat�i�;�' � T.� '� ���
0 OWNER
YOUR E-MAIL ADDRESS
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i i.vr r,,. i i NAME: Oj-t--� -----�� r y --
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TENANT �DRESS: CITY STATE ZIP
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CD��CTOR NJ��: . lJl. � � / ..... r/�' � . 0��� �� �� .
SUBMIT A COPY OF STATE LTGENSE � p
YOUR STATE "' - ExP Da'rE ,�� ^� O
LICENSE, BOM3 AND STATE BOND #_� � �j � EXA DATE IAC ���oZ fl,
CERTIFICATE OF ADr.ltESS: t! �Y� .!V i✓ _�i���_STATE�Zn
INSiJRANCE
PHONE �,� ,� y�- ��,g a�� F,� a
PERIVIIT TYPE "0,i1"GLE FAMILY ❑ TWO FAMILY ❑ TdWNHOUSE
TYPE OF WORKc I o t�w
)ETAILED DESCRIPTION O�
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FEEB ARE BASED ON $10.00 PER FIXTURE, EXCEPT VVHERE NOTED. FIXTURES: (lNDICATE TOTAI, NTJMBER OF EACH BELOVI�. ;,
_ BATH SINK/LAV FLOOR DltAINS SiiOWER WATER PIPINd y
_ BATHTUB GAS PIPING (NEID CITY LIC) _ SWIMNIING POOL WATER SOFTNER (S35)
CLOTHES WASHER � KITCHEN SINK WATER CLOSE'f �BACKFLOW PREV. (a23)
_ DISFiWAS1iER _ LAUNURY TRAY �WATER HEATER ($35) � FOR IRRIGATION
� WATER IvIETE12 � OTHER
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THIS IS AN RPPLICATION FOR A PERMtf-NOT VALID UNTIL PROCESSED
I hereby apply fflr a plwnbing perrnit and i acknowledge that the informatian above is complete and accurate; tisat the wtirk will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Cons�uctian 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 wiil be in accordance
with the approved plan in the f wor whie�t ,quires review and approval ofplans, % j1
SIGNATURE OF APPLICANT pRIIdT NAME,�y� fj?%t D�A ': DA'CE IQ �/ ���/�(,
APPRQVAL INSPECTORS SIG A DATE
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City of Fridley
Building Inspections Depar�tment
6431 University Avenue NE, Fridley, MN 55432
763-572-36Q4
FAX; 763-502-4977
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