P - 48293Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2012
Permit No.:'L1111i1J1
Received By:' � N 1'
Date Rec'
DATE Z-�` I Z YOUR E-MAIL ADDRESS
SITE ADDRESS �$ �3 �"�GEC ��ti��q %�1/G •
THIS APPLICANT IS: ❑ OWNER f�CONTRACTOR
PROPERTY NAME:. O �
OWNER/ ADDRESS: S�S� !-I acl�� a�►„�„? crrx r�'d t e� STATE P SS'432
TENANT punuF• 7G'� �J �.� _ 1 S1L1 �
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
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ei:cti,f"s'i:�:1i.�%�/L!t%fij►�� " � � L�f�ILJJ�.�II�/
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PERMIT TYPE I �SINGLE FAMILY
TYPE OF WORK: I � ��'''
DETQILED DE�RTPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
r u� 2 ..�.1
�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER � WATER PIPING
_ BATHTUB � GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. (E15)
DISHWASHER LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
- � WATER METER _ OTHER
I hereby apply for a plumbing
conformance with the ordi c
not a permit but only an p
with the approved plan i e
SIGNATURE OF APPLICANT
APPROVAL INSPECTORS SI NA
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
it and I ackn ledge that the information above is complete and accurate; that the work will be in
d codes of th City of Fridley and with the Minnesota Construction Codes; that I understand this is
-p��rni' 1 o start without a permit on site; that the work will be in accordance
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-49'77
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� DATE — C� — I Z
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