P - 48393Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � .► I b '""', d
SIT'E ADDRESS SZa �' R.�D�
THIS APPLICANT IS:
PROPERTY NAME:
OWNER/ ADDRI
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
PLUMBING Permit No.: �1 �'�'� ��i �
RESIDENTIAL APPLICATION Receivect By:��.'_
CITY OF FRIDLEY D����'�� ��� °� � �r��;
EFFECTTVE 1-1-2012
r-. YOUR E-MAIL ADDRESS
�$'C' % R:rJk..� �r� �S-�� .
�'S�WNER _ ❑CONTR.ACTOR
NAME:
STATE LICENSE #
STATE BOND # _
ADDRESS:
PHONE
FAMILY
TYPE OF WORK: ( � NEw
Nc.�a
DETAILED DESCRIPTION OF WC
�
� TWO FAMILY
�
��70 ��I _�r�O V� `
❑ REPLACEMENT
CIT`Y_
FAX
� TOWNHOUSE
�STATE�`1 V`SIP_
EXP DATE
EXP DATE
STATE ZIP
o.� OC' �" „
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTCJRES: (INDICATE TOTAL NUMBER OF EACH BELOW). MiNIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BAT'HTUB GAS PIPING (NEED CITY LIC) SVJIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTTL PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the informatio above is complete and accurate; that the work will be in
conformance with the ordinanc and codes of the City of Fridley and with e innesota Construction Codes; that I understand this is
not a permit but only an appl' tion for a permit and work is not to start itho t a p ya�t on site; that the work will be in accordance
with the approved plan in th of all w ich requires review and a prova of p .���, / Q_ \ �",��o ^� o�
SIGNATURE OF APPLICANT PRINT NA
^'�'0'' DATE
APPROVAL INSPECTORS E DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977