P - 35501Building PLUMBING Permit No.� �� ``lS
Inspections RESIDENTIAL APPLICATION Recei�ed By:
763-572-3604 CITY OF FRIDLEY D�C���� ��� 2010
763-502-4977 FAX EFFECTIVE 7-1-2010
DATE YOU E-MAIL ADDRESS
SITE ADDRESS / .� � / ��,� T %-a��.i► /1��
THIS APPLICANT IS: ❑ OWNER ❑CONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSUR.ANCE
PERMIT TYPE
TYPE OF WORK:
ADDRESS: CITY STATE ZIP,
PHONE:
STATE LICENSE #_
STATE BOND # _
�wDxESS: � 7
PHONE --���
SINGLE FAMILY
❑ NEW
r
❑ TWO FAMILY
� PLACEMENT
EXP DATE
EXP DATE
CITY .�'1.� S'!
_ F� � _
❑ TOWNHOUSE
DETAILED DESCRIPTION OF WORK �i�� Tj9 L /i✓'A %�/j J/�4( �jG'
/�'�"' ZIPSS�.�d
7Ef'r �` �7 %�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER � WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CIA7'I-IES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15j
_ DISHWASHER _ LAUNDRY TRAY _WATER HEATER ($35) FOR IItRIGATION
_ 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 work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the o all or _ quires review and approval of lans. i /
SIGNATURE OF APPLICANT PRINT NAME C���� G21¢ /`✓ DATE ��-l4' '�
APPROVAL INSPECTORS SIGNATURE . -
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977