P - 46276Building
�nspections
763-572-3604
763-502-4977 FAX
DATFs �Q � � 1 "
SITE ADDRESS _
THIS APPLICANT IS:
PLUMBING
RESIDEI`�TIAL APPLICA'� �(�l`�T
CITY OF FRIDLE'�'
EFFECTIVE 7-i-2010 . __
YUL12 E-n�fAIL
❑ OWNER �`CONTRACTOR
PROPERTY NAME: ,G�..YI Yl � Jni�► Y�SC11�1
OWNER/ ADDRESS:�'� CITY
TENANT
PHONE:_ �_ �. � �--�
Permit No.:
Received By: � �
Date���: �A �
A
CONTRACTOR NpME:
SUBMIT A COPY OF STATE LICENSE # EXP DATE
YOURSTATE
LICENSE, BOND AND STATE BONll # �r� _�a�_i �dn °� DATE
CERTIFTCATE OF ,o,DDx�ss: 3670 Dodd Rd. crrY _ sTa� z�
INSURANCE PH�� Eagan, MN 55123 F.�x
PERMIT TYPE
TYPE OF WORK:
SINGLE FPcMII.Y
❑ NEW
❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
DETAILED D$SCRIPTION OF WORK �C�1 ��•��
FEES ARE BASEA ON $]0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMI3ER OF EACH BELOV�. MINIMUM FEE
$35.50.
BATH SINK/i,AV FLOOR DRAINS SHOWER _ WATER PIPING
BATHTUB GAS PII'ING (NEEl� CITY LIC) SWIMMTNG POOL _ WATER SOFTNER ($35)
~CLOTHES WASHER HITCHEN SINK � WATER CLOSE7" _BACKFLOW PREV. ($15)
DISHWASHER LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
� WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII. 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 o the City of Fridley and with the Minnesota Construcrion Codes; that I understand this is
not a permit but only an application for a pe work is not to start without a plrmit on site; that the work will be in accordance
with the apprbved plan in the case 11 work'w r review and appr qval of plan
SIGNATURE OFAPPLICANT AME �JGi �S '� P�_DATE�i1 "��"�� �
APPROVAL INSPECTORS SIGNA
V City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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