P - 45834Building PLUMBING Permit No.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date Rec'd: 0\�
763-502-4977 FAX EFF�cTivE i-t-ZOti
DATE 6 ' �, -
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
�'OWNER
NAME:
_ YOUR E-MAIL ADDRESS�
ftit�i� �Irlda
PHONE: � % � �� / I I �� rJ
CITY
CONTRACTOR NAME:�%%��-
SUBMIT A COPY OF T
YOUR STATE STATE LICENSE #
LICENSE, BOND AND STATE BOND #
CERTiFICATE OF p,DDRESS: CITY
INSURANCE
PHONE FAX
PERMIT TYPE �SINGLE FAMILY
TYPE OF WORK: f/� NEw
1
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
❑ REPLACEMENT
,��-� � � y� 9,_'�f flI f�
❑ TOWNHOUSE
5i�
STA
EXP DATE
EXP DATE
ss��a
STATE ZIP_
�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50,
X BATH SINK/LAV FLOOR DRAINS �C SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK � WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR [RRIGATION
WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL]D 4JNTIL 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� the Ci f Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a perm an ork is not to start without a permit on site; that the work will be in accordance
with the approved plan in the ase f all ork i r�'quires review and approval of plans.
SIGNATURE OF APPLICANT ' PRINT NAME Jo h n ./.�._�.' DATE "' -
��-�-1�-�
APPROVAL INSPECTORS SIG TURE t; L "�I __ _ __ DATE_
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977