P - 36724�
Building
�nspections
763-572-3604
763-502-4977 FAX
DATE ��% `7 �/ e
SITE ADDRESS � Y� �
THIS APPLICANT [S:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
YOUR E-MAIL ADDRESS
r�,� �,�� � ,
❑ OWNER '�NTRACTOR
NAME: 1 CJD/ /�i K���.«<
ADDRESS: I�3 % �C7/!{-C/tjL t �1 CITY
PHnNF.• 7L2 - ��� � IV��
NAME:
`e �S r
Pe��t No.aal�b � 3 �
�c�Received By �
I�t�'�e� C � �+ 2
ATE ZIP.
STATELICENSE# ����p��v� vv�n.v..�..+...+ •.•� EXPDATE
STATE BOND # a n i a EXP DATE
ADDRESS: �7hakopee, MN 553�I�1f STATE ZIP,
PHONE �i�Z�,L�S-�R�3 FAX
�INGLE FAMILY
❑ NEW
❑ TWO FAMILY
'�REPI,ACEMENT
❑ TOWNHOUSE
�
DETATLED DESCRIPTION OF WORK �- � er�r-C +�- %i /�C�i �--� �� � �� �
FEES ARE BASED ON $10.00 PER FIXNRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MIN[MUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIP[NG (NEED CITY WC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER � KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
DISHWASHER LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATTON
— WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
ere y 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 pe it and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case of a requires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME �i�7-i'lIC �//��+� � DATE ��� %�!v
APPROVAL [NSPECTORS S1GN
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977