P - 45689Building PLUMBING Perm�t No.: �6 i7���
Inspections
763-572-3604
763-502-4977 FAX
RESIDENTIAL APPLICATION
DATE _ /� � �� �
SITE ADDRESS '3�_
THIS APPLICANT IS: ❑
PROPERTY NANtE:
OWNER/ ADD�ss:
TENANT
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
�'ONTRACTOR
--- .s.
CITY
Received By:
Date'�4i: � ��—�
sTa-rr�9�1 z�P.rsY,�Z
STATE LICENSE # OL�.��p/� J EXP DATE �oZ `� �-' / I
STATE BOND # /SO % 7�,ZO � EXP DATE �2- 3 I"� I
ADDIZESS: 3�O �,�MN P�r' �-�t P.� CITY T CYWIoCJ STATE�ZIPSSyy/
PHONE /d S " �1 /S " DiG `f fj
�SINGLE FAMILY ❑ TWO FAMILY
TYPE OF WORK: I� NEw
DETAILED DESCRIPTION OF WORK
� �"m.`/��'
�REPLACEMENT
.,
r
_ FAX /( c3 ' i /c.9 "
❑ TOWNHOUSE
S�`�+� �3
.._ .L i_
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: QNDICATE TOTAL NUMBER OF EACH BELOW). MINIMLJM FEE
$35.50.
� BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
Z 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 APPL[CATION 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 the cas �'i rk wAhich� equires review and approval of plans.
SIGNATURE OF APPLICANT �.L i�l(D�j_i PRINT NAME i i�i /�p �ij I- DATE /Q �Z6 �/
APPROVALINSPECTORSSIGNATURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977