P - 35479���5 �.
Building PLUMBING Permit No.
Inspections RESIDENTIAL APPLICATION Received By: "� �
763-572-3604 CITY OF FRIDLEY Date Rec'a:�
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE � -/� - /
S[TE ADDRESS �Z
THIS APALICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAIL ADDRESS ��� � Si
❑ OWNER �"CONTRACTOR
NAME: Q � �° ,s'�7✓1
ADDRESS: � a..�, r c�,.s r� �pp �
PHONE: �6� S�d - %�
NAME: �p t� � @�i� � G,!
STATE LICENSE #��—
STATE BOND # /�
ADDRESS: Q vX ��0
PHONE L (5 �- ��4� O�%
�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
�] REPLACEMENT
CITY
_ FAX /b
❑ TOWNHOUSE
�'' _ � ,
ATE ZIP,
EXP DATE ��' 3�- � f
EXP DATE �v� -�� l �
STATE��ZI P 3'��
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIX'I'URES: (INDICATE TOTAL Nl1MBER OF EACH BELOW). MiNIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHNB GAS PIPING (NEED CITY LIC) _ SWIMMING POOL WATER SOFTTIER ($35)
CLOTHES WASHER � KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
� DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR (RRIGATION
_ WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing pennit 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 permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan i the ,c�a, e� 1 work which requires review and approval of plans.
SIGNATURE OF APPLICAN7����L PRINT NAME DATE
APPROVAL INSPECTORS S�G1C'ATi71F� I�.�an � r� ne�rc n a t� �.
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977