P - 48073Building PLUMBING � Permit No.: � U
Inspections RESIDENTIAL APPLICATION Received By:�
763-572-3604 CITY OF FRIDLEY �Z
,
763-502-4977 FAX EFFECTlVE I-I-201I �C'D � �
DATE i Z- 1� YOUR E-MAIL ADDRESS __ i�I'Cr»'C�h � M�m p-� ��„�
SITE ADDRESS �'3 �� �.� � ,�QJ �
THIS APPUCANT IS: ❑ OWNER $CONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTiFTCATE OF
INSURANCE
PERMIT TYPE
ADDRESS CITY
PHONE:
ATE ZIP
STATE LICENSE # ��0"79�`� � EXP DATE /a o'2a / Z
STATE BOND # I� 150 0 li3W ln EXP DATE ,� v/2�
ADDRESS:_�� • c�o'X `�+'SJS I CITY .J'� ry�1er IT321'v� HYiS STATE�y�ZIP_
PHONE _ (stsl ` Zy� -/DE�� FAX
FAMILY 0 TWO FAMiLY � TOWNHOUSE �
TYPE OF WORK: � NEW � REPLACEMENT
DETAILED DESCWPTION OF WORK �.�"�I/1s+r�. �A(,,4 i%� �^ ��n,,.r.yr-�
,
FEES ARE BASED ON SI0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). M1N�MUM fEE
535.50.
� BATH SINK/LAV 1 FLOOR DRAINS � SHOWER WATER PIPING
1, BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTN6R (S35)
CLOTHES WASHER KITCHEN S1NK � WATER CLOSET BACKFLOW PREV. (SIS)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
TH[S IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby appiy 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 acc rdance
with the approved plan in� se of work w�c r quires review and approval of plans. �+
SIGNATURE OF APPLICAIJ�_,`- ------Pi�}N�' NAME , j..c.�c.r.� �� � Q57�-4� DATE �o�- �' �/
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977