P - 47401Building
Inspections
763-572-3604
763-502-4977 FAX
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-2011
DATE (.� -1 S- I I YOUR E-MAIL ADDRESS
SITE ADDRESS ),� �' � G r t�e. ( L P� �L j^ ,.�
THIS APPLICANT IS: ❑ OWNER I�ONTRACTOR
Permit No.:
Received ' ' ""v'
Q�(`� .����----r�-zo�1
D�'f�`R'ec'd:
PROPERTY NqME: j"S'(yj,� v� P1,.,1. r,�
OWNER/
TENANT �DRESS: I 3�' / C-� � r 1 Z � o, IL �� CITY F,r , n ��� STATEy�ZIP
PH(1NF�
CONTRACTOR NaME: v e,�s��-� ,�(,�-�,.b� y �.
SUBMIT A COPY OF —
YOUR STATE STATE LICENSE #�y�� - Q U� EXP DATE I Z- 3(-( �
LICENSE, BOND AND STATE BOND #(� L(? Q �I �j (,� �./ � 6 EXP DATE l Z- 3(-(/
CERTIFICATE OF e,DDRESS: .�i 6 6 i �'� ! �� U L �w CITY �. �;�..,,, k,�,. ,� 5 e STATE V"h v ZIP s5p°�
INSURANCE pHONE '�.� ;� - 2 3 �' - �.j -� � 3 p�
PERMIT TYPE
TYPE OF WORK:
�SINGLE FAMILY
❑ NEW
❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
DETAILED DESCRIPTION OF WORK t'�.� �-c� .� .�' �,� .� f a t�� � G v� .� �- u L � S L w.�t � �
u- .e_
� ix � �... �- n - -� / ,._ . , .
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
I� BATH SINK/LAV FLOOR DRAINS 1r 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
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 permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in th� s�of a�l wqrk �,hich requires review and approval of plans.
SIGNATURE OF APPLICANT �..5 A�_ PRINT NAME J� , �c <<..� �(�_ � DATE (7 ' I S" lI
APPROVAL INSPECTORS SIGNATURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977