P - 47282Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �%�r3'
SITE ADDRESS �
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER �ONTRACTOR
ADDRESS: l% � Ch Y` t5'�"��73Y1 (���J� CITY,
PHONE:��I 3 — ��% y —, � �J�'1 -
Permit N
� - - - • : '��\t�F.GP�i
� . �.�,. � �� � j11 , j
CONTRACTOR NaNtE: T� ('��er�.,�cpr �l a�.-�.Iz; �• �
SUBMIT A COPY OF STATE LICENSE # v� y��� EXP DATE l ri�—� 3I— � J
YOURSTATE �
LICENSE, BOND AND STATE BOND # p Y. � � L.L, EXP DATE
CERTIFICATEOF ADDRESS: �a. � �/��Y-, �} CITY I�t�okci STAT�_ZIPF�?3(7�
INSURANCE pHONE �p3_C'j'a ��G FAX ~( (�'3 ��,�j�q
fi�T:iu1111IIM•/��I
TYPE OF WORK: I� NEw
FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
DETAILED DESCRIPTION OF WORK i�,C�GC� �AS(�,�c-- \� ��--e_r—
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MININNM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL
CLOTHES WASHER KITCHEN SINK WATER CLOSET
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35)
WATER METER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
WATER PIPING
WATER SOFTNER ($35)
BACKFLOW PREV. ($15)
FOR IRRIGATION
_ OTHER
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 perm� and w is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case rk w'c e ui�,review and approyal of ans. 1���� ��
SIGNATURE OF APPLICANT ME ll:��J.F,fCe.G�f11.Y DATE
APPROVAL INSPECTORS SIG � DATE � ''
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977