P - 48335Buildin�
Inspections
763 �72-360�
76,->a�-49�7 F�.x
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TENANT "'�� �� � --�
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CONTRACTOR N�rviE Y� �� �� L�1.�- (�I �.... �►a� �. y
SU[3MIT A C:OPY OF
YOUR STATE STATL' LICL-'NSE # EXP DATG
LICGNSE. BOND AND STATE BOND # GXV DATE
CERTIFICATE OF ApnRess: �i� � C �'"� �� .�, j�- 1� t ciTV F�' �� �c'? �- sTATE tt� z[P ����3�
INSURANCE pHONE �Z l�� f S�`E ����l FAX
PERMIT TYPE
TYPE OF WORK:
�WGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
� REPLACEMENT
❑ TOWNHOUSE
t._,
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 PIP[NG (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WAT�R CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY 1 WATER HEATLR ($35) FOR IRRIGATION
WATER METER OTHGR
�Number�offixtures a) $t0�:00 ��� x �10.p0 � ���
Nwnberoffixturesli�$1�.00 � x$15.00 S
Number offixtuxes �? S�5_�� �' ,� ��5:00 � �'' =,. � `
State Surcharge $ ' 5.00 ''
(MINIMiTM $40.00} �'� Tota# — � =_� �.� `� �'' � .
TH1S IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSGD
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 Mim�esota 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 pian in the c�e of all wark wh�ch r yuires review and approval of plans.
S[GNATURE OF APPLICANT � LA-i+.. -�a �= PRINT NAME �.� i t,j �C r..,�t !'• DATE I`�� - I�
APPROVAL INSPECTORS SIGNATU1tE / a�J1 �� �--DATE ^ L_7 �
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN ��432
76�-572-�604
FAX: 763-502-4977