P - 47274Building
Inspections
763-572-3604
763-�02-4977 FA�
DATE li ZU � I �
SITG ADDRESS
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMTl' TYPE
TYPE OF WORK:
���T1V�BIN� Perm�t No.:�6I ����
Rij 5���+ l�T�'��.� �.PP�I�;��'IDN Received By3��_
��'��`' 0� ��DL.��T �i� � f �
EPFECTNE 7-]-2011
YOUR E-MAIL ADD}2FSS
❑ OWNER '�CONTRACTOR
/�
NAME: ,�/ I�/L�� I � 'W
ADDRESS: "�� "�� (�►'�/(/6�� y�
PHONE: � �?)' � �I � I���
NAME: I ��V i/l �Wj�i�,C�l �
STATE LICENSE t! ���
STATE BOND #
ADDRESS: � � �� �� �JL�
PHONE � lY 3� �S � ���
�SINGLE FAMILY
�
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
�PLACEMENT
_C[TY YYl �11� STA
EXP DATE
EXP DATE
_CITY STAT
_ FAX � ✓ �- ' � ��
❑ TOWNHOUSE
FEES ARE BASED ON $] 0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATERPIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATERCLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LJNTIL 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 and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the of 1 wor c reyuires review and approvj� f lans�^ �rp�,/p„ ,7 �J
SIGNATURE OF APPLICANT �7���� C��l� PRINT NAME /�� �'�'G�/"'�� DATE �V' f . lI
APPROVAL INSPECTORS SIGNA'I'URE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977