P - 45296Building �� PLUMBING permit No.: ��'� ! v�
Inspections �ESIDENTIAL APPLICATION Receive�B�� ��,
763-572-3604 CITY OF FRIDLEY Dat�e�'d:
763-502-4977 FAX FFFECTrvE �-�-zoi, .
DATE �I �l � 1
,,.
SITE ADDRESS _ �� ✓
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
YOUR E-MAIL ADDRESS
�'l��t't L'� � /� t"f'
❑ OWNER L�ONTRACTOR
NAME� �i'/ � �
ADDRE S: � I% �'�'W N,✓'C, �'�_�,� �
PHONE: � 7 �"" � �L °Z� '' D ���
NAME � %'�ft��i'��%/_�_
STATE LICENSE # ��
STATE BOND #
ann�ss: ��-`�� /l'lct�/t �f �iJ� � 1
PHONE �ia? �"�" �,d �' ���'l
TYPE OF WORK: I� NEw
FAMILY
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
�REPLACEMENT
❑ TOWNHOUSE
TA
EXP DATE
EXP DATE
Zf STATE ��ZIP�S��
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.SQ
BATH SINK/LAV FLOORDRAINS SHOWER WATERPIPING
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 IRRIGATION
� WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL 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 t � all}�`�� k ich •equires review and approvatl �o }'ans./`��
SIGNATURE OF APPLICANT � c. G-/"' �%'"C� PRINT NAME /�L! K- (..�`'��Y'�'I%' DATE � /
APPROVAL INSPECTORS SIGNATiJRE 1 DATE --�7 /' �
_+��
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977