P - 48322Building PLUMBING Permit No.� �I% �
Inspections RESIDENTIAL APPLICATION Received By:�
763-572-3604 CITY OF FRIDLEY �.?a�e�e�`'��:� t�
763-502-4977 FAX EFFECTTVE i-i-ZO�z
DATE I l:3 I 1 I� YOUR E-MAIL ADDRESS +°��� ��'wS �,�r �"'� t'" T� � V`�-'�
SITE ADDRESS % �,�,5' �� c,.�C.0 `-�► �P'. . � r" i � �y ; M r�J
THIS APPLICANT IS: �JOWNER ❑CONTRACTOR
PROPERTY NAME: ��- s� 1�yF ,,`� -i�r
TO NANT ADDRESS: /� �'; •r'i c.� •;, {� r`. CITY 1�,r� STATE fVl►.�IP S�3 �
PHONE: 7E� .3 '— �% �/ ^ i � 3—U
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE STATE LICENSE # EXP DATE
LICENSE, BOND AND STATE BOND # EXP DATE
CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE
PHONE FAX
PERMIT TYPE �SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEw ��2EPLACEMENT
DETAILED DESCRIPTION OF WORK R�-� I��-t- •-}k. ��{ S h.�x� c,r �F� X-F-�r� ,`ft„ �e_I"- �Q S�,�C 7zi�c��--
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
f BATH SINK/LAV FLOOR DRAINS I SHOWER WATER PIPING
1 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
Number of fixtures � $10.Q0 � x $10.D0 - g � ``` �
'�iumber of fixtures �$ i S.OQ x$15.00 -$
Nun�ber of fixtures � $35.0(? x $35.OD -- $
�taTe Surcharge . � 5,00 ,
n1INI1�IUM �4Q.Ot1 ' Total = $ "'� i , � '�,
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 to start without a permit on site; that the work will be in accordance
with the approved plan in a,se of all w r whic requir r v' w and appro of plans.
SIGNATURE OF APPLICANT Ij�i�],T��NJk; GLfiJ�_t�f �r.i,� S DATE �
APPROVAL INSPECTORS G ATURE Y/�� l!.(' ' DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977