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:
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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