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P - 37228Building PLUMBING Permit No.: � I(g(� �� Inspections RESIDENTIAL APPLICATION Re�eivecl By:� 763-572-3604 CITY OF FRIDLEY ��"�3-elb����;�� 763-502-4977 FAX EFFECTIVE 7-I-2010 DATE I I� l"�O YOUR E-MAIL ADDRESS SITE ADDRESS % b o� ���� �' �� ai � r�t. L� � i THIS APPLICANT IS: ❑ OWNER ❑CONTRACTOR PROPERTY OWNER/ TENANT CONTRACTOR SUBMIT A COPY OF YOUR STATE LICENSE, BOND AND CERTIFICATE OF INSURANCE s � �lLC S CS F.J ADDRESS: �=J �F--�„ -� CITY PHONE: r ,, \`�C i{-f� �\ 1 C +� STATE LICENSE # �S � Z� C EXP DATE ATE ZIP STATE BOND # EXP DATE ADDRESS: f`( Z Y ��� S�- '=% CITY �vt�A � S STATE �Lt ti ZIP `�f PHONE C� i 2- �� `% �i Ci � FAX PERMIT TYPE I� SINGLE FAMILY � TWO FAMILY O TOWNHOUSE TYPE OF WORK: � NEW ❑ REPLACEMENT DETAILED DESCRIPTION OF WORK FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BETAW). MINIMUM FEE $35.50. BATH SINKlLAV FLOOR DRAINS SHOWER WATER PIPING BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35) CIATHES 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 an I acknowledge that the information above is complete and accurate; that the work will be in conformance with the ordinances and des of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a permit but only an applicati erniif'and work is not to start without a permit on site; that the work will be in accordance with the approved plan in the c f all work which requires review and approval of plans. � r( �`� t� SIGNATURE OF APPLICANT PRINT NAME ��-�f— 6 dW C'r. DATE APPROVAL INSPECTORS SIG TURE City of Fridley Building Inspections Department 6431 University Avenue NE, Fridley, MN 55432 763-572-3604 FAX: 763-502-4977