P - 35799�
Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � C� - t �
SITE ADDRESS ����
THIS APPLICANT IS:
PROPERTY J�p
OWNER/
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAI L ADDRESS m� P��i ��t� (�
❑ OWNER �ONTRACTOR
�!it�u'' i! � � AZ 2 �1
TENANT ADDRES^
�
CITY
CONTRACTOR NAME: � ' '� P c� -�
SUBMIT A COPY OF STATE LICENSE #� Ii� (o � 3
YOUR STATE ` , �� OQ
LICENSE, BOND AND STATE BOND # W
CERTIFICATE OF ADDRESS:�� � Z� I S A� E IV „� ��Ty (
INSURANCE pHONE ��`���6�,� °' %,��� FAX
PERMIT TYPE I� SINGLE FAM[LY
TYPE OF WORK: I� NEW
DETAILED DESCRIPTION OF
❑ TWO FAMILY
�REPLACEMENT
i
_ �. __ �• .
Permit No.: /�J� �/(J(}�" �U
Received By:' Y�
Da�!�����'� ,,_ � �
d � ��_
L L G (t.o•�
EXP DATE
EXP DATE
�
i/_2 ..11?I/ �
�TOWNHOUSE
0
1`l. ����
ATE�(�ZIP�
_ �'f -
n
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW), MINIMUM FEE
�$ .50.
BATH SINK/LAV FLOOR DRAINS � SHOWER WATER P[PING
I 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 IRRIGATION
_ WATER METER � OTHER ,�qs ��bF
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L PROCESSED
I hereby apply for a plumbing permit and I acknowfedge 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 ' an ork is not to start without a permit on site; that the work will be in accordance
with the approved plan in the ase � ork quires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME L0.f w �/ T� �G1 � [ ' �_DATE� -• �:� � (iI
APPROVAL INSPECTORS SIGNATU �. -2�' neTF �7//
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977