P - 37137�3uilding � ��,������i I Permit No.:
�n�pecti�ns
763-572-3604
763-502-4977 FAX
DATE �__� ��
SITE ADDRESS �
THIS APPLICANT IS:
PI�OPE12'I'Y
OWNER/
TENFiNT
c�N��cTOx
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PEbt1V�IT TYPE
'i'YPE OF' V'dORK:
��j ����j �'�'Ii�� E�.�����.����� Received By{�I
�I�'�' �� �������' D��`�''�� 1/
EFFECTIVE 1-1-2010 _
❑ OWNER '�CONTRACTOR
NAME: -..� �
ADDRESS: � � CITY STATE�ZIP���;,
PHONE:� ' �E„
NAME: �'il"Ie�ir1�11QC1 PIUiTlbin�
STATE LICENSE # # 6� �� ! EXP DATE
STATE BOND # EXP DATE
ADDRESS: G�r+an MI\i `irii'�`� CITT' STATE ZIP
—�-- ,
PHONE _ FAX
�SINGLE FAMILY
❑ NEW
DETAIL,ED DESCRIPTTON OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
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
^ gp��g GAS PIPING (NEED C1TY LIC) SWIMMING POOL _ WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET _ BACKFLOW PREV. ($]5)
� DISHWASHER ^ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGA110N
WATER METER _ OTHER
THIS IS AN APPLiCA7tON 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 wil] 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 case of all work which requires review and approval of plans.
:�� � , � � � � _ .
SIGNATURE OF APPLICANT
City of �ridtey
Build��ag �nsp�c�io�s D�p�r��ae�t
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
' FAX: 763-502-4977
DATE ;i-� Ia-�o
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