P - 48347Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �� � [ — ZO �'
SITE ADDRESS � �_'
7HIS APPLICANT IS:
PR PER
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
YOUR E-MAIL ADDRESS
��.n n e 1►� �� C '� �'- f«� ��./ �s �=13 Z
❑ OWNER
O TY NAME:
OWNER/ ADDRESS:
TENANT
V 1'� CITY
- A Y
Permit No.: `°�"� � ���- ,'-?
Received By: r��_
� _ �,j _ .
�C��'�� �
STATE ZIP
CONTRACTOR NAME I� e`�C'� ' c�c� ( C� `-' �',c 1�:�t.y
SUBMIT A COPY OF
YOUR STATE STATE LICENSE # EXP DATE
LICENSE, BOND AND STATE BOND #t EXP DATE
CERTIFICATE OF ADDRESS: ' �� 15C: C'._SC: � CITY -�4_,S C.r�„ r STATEL'�7i l ZIP .S-S�i �
INSURANCE pHONE_ _�`7L�,.5 ��`� ' S7S Z FAX
PERMIT TYPE
TYPE OF WORK:
�CSINGLE FAMILY
�
NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
❑ REPLACEMENT
,
C�-,.1 �r r . �'».'
❑ TOWNHOUSE
�% <� C t.:i.C.:v'V�. rc:.' ��-1
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
Number of fi�iures @ $70.OQ x �10.00 = $
Number of #ixtures rz $IS.DO x $15.�4 - $
�TUmber of fixtures (a? $3 �_00 x $35.UD - $
State Surc�aazge � �.00
(11TINIMUt�7 $�O.di�) Tota1= �
TH]S IS AN APPLiCATION FOR A PERMIT-NOT VAL1D UNTIL PROCESSED
I hereby apply for a plumbing pennit and I ackn ledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and cod e City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application it and work is not to start without a ermit on site; that the work will be in accordance
with the approved plan in the c at which require view and apR�� of 1a ��� ���n � ��^ Z� O
SIGNATURE OF APPUCANT �.._ PRINT NAME^--�C�'\ � �y `"'v \ DA7E �
APPROVALINSPECTORSSIGNA -" DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977