P - 35448Building PLUMBING Perrn►t rlo.: �
Inspections RESIDENTIAL APPLICATION Re�ei�ed sy:_�a�/
763-572-3604 CITY OF FRIDLEY Da� '�� �►�+ w�� n 1
763-502-4977 FAX EFFEC7TVE 1-1-201 I I� '
DATE �' IL' II YOURE-MAILADDRESS G(bDVC'..t, beuonra. aI� � Q119(-l\'rCa�4�
S[TE ADDRESS �ys� C fee.k �ack L�
THIS APPLICANT IS: ❑ OWNER �C�ONTRACTOR
PROPERTY NAME: kGttcn M �C.�1\oc.ti
OWNER/ ADDRESS: I�SN C_Ce�k ?ac k Lt�1 CITY �iZ� �L�= Y STATE/1 i1�ZiP�S��Z
TENANT
PHONE:
CONTRACTOR NAME: �aVQ ;J��c,.c,r� p�.un�.c3���-
SUBMIT A COPY OF STATE LICENSE # OCv�-k l2 t- P[h EXP DATE �'Z- l� -1
YOUR STATE �
LICENSE, BOND AND STATE BOND # EXP DATE
CERTTFIGATE OF ADDRESS: � n�I31 15�3^� Ln� Nw CITY (Zar� STATE_ li�i ZIP 553r��
INSURANCE pHONE %�e3 �00^ C�S`o� FAX
PERMIT TYPE INGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW REPLACEMENT
DETAILED DESCRIPTION OF WORK ��T,qct �_� a- c-cDa: r 1 t�ck c� t" �«; u a�oti a.JWC
�m:ltr cci�
FEES AR£ BASED ON S 10.00 PER FIX'fURE, EXCEPT WHERE NOTED. FIX"CURES: (INbICATE TOTAL NUMBER OF EACH BELOW). MiNIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHNB � GAS PIPING MEED CITY LIC) SWIMMING POOL WATER SOFTNER($35)
_ CLOTHES WASHER KITCHEN SINK WATER CLOSET )C'BACKFLOW PREV. ($15)
DISHWASHER _ LAUNDRY TR.AY AT�R HEATER ($35) 7 FOR fRRIGA'fION
ATER METER OTHER
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THIS IS AN APPLICATfON FOR A PERMIT-NOT VAL1D UNTIL PROCESSED
T 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 in the case all work which requires review and approval of pla�
SIGNATURE OF APPLICANT PRINT NAME �.� �k DATE 5-��--�/
APPROVAL INSPECTORS SIG TURE DATE
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City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977