P - 35458Building PI,�TIVIBING
Inspections �+ SIDEN�'IAL APPLICA�'ION
763-572-3604 C�TY OF FRIDLE�'
763-502-4977 FAX EFFECTIVEl-1-20]]
DATE G � �
SITE ADDRESS _
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
SiJBMTI' A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERNIIT TYPE
�YOUR E-MAIL ADDRESS
❑ OWNER �CO
NAME: YG� e �
ADDRESS: IS� G�{'l�
PHONE: 1`�'�` Z�Z-
NAME: � �
STATE LICENSE #
STATE $OND #
ADDRESS: Oi�! „'W�l��"��� ��✓� CITY�
PHONE ����._l�" °LI � FAX _�
�jSINGLE FAMILY � TWO FAMILY ❑ TOWNHOUSE
�E oF woitx: I ❑ NEW
DETAILED DESCRIPTION OF WORK
�REPLACEMENT
Permit No.:
Received Byf:� lyt
�a� I�e�' � � !�
ATE �'/U ZIP JrS�
EXP DATE
EXP DATE
�_STATE�_ZIP ✓ Z
�-�s�- �'!�R
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXNRES: (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 WATERCLOSET BACKFLOW PREV. ($15)
DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
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 per,� �t and war� is not to start without a permit on site; that the work will be in accordance
with the approved plan in the�� all wo c whici re �fes review and approval of.plans.
SIGNATURE OF APPLICANT ���� .�AP&�NT I�QN1E �`/N�- �Y� DATE �
APPROVAL INSPECTORS SIGNATURE �i �,II��l� L DATE
. City of Fridley �
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977