P - 36713Building
Inspections
763-572-3604
763-502-4977 FAX
5-c.�—�
S1TE ADDRESS _
THIS APPLICANT IS
P��JIVI�ING
�SIDEl�T'�'It�� AP�LICA�ION
. CITY O� F��EY
EFFECTIVE ]-1-20ll
YOURn E-MIAIL ADDRESS
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❑ OWNER '�1CONTRACTOR
PROPERTY tvatvlE: �V ��-YY� i'�7� I, '�G?G2✓�oI
OWNER/ ADDRESS: r—�����— CITY.
TENANT —�? �� � g
PHONE: i
Permit No.2..6
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.. ,
TE . ZIP
CONTRACTOR NAIvIE: ,
SUBMTI' A COPY OF STATE LICENSE # River �itv Pi�mb��, ,� EXP DATE
YOURSTATE � � ��
LICfiNSE, BOND AND STATE BOND # 8290 Main St N E��F � EXP DATE
CERTIFICATE OF ADDRESS: FI'If'I) v MN F���+' _CITY STATE ZIP
INSURANCE
PI�ONE (763) 754-21 �9 ���T!'��<•z �� .�=�na� FAX
_ PERMIT TYPE
�rE oF woRx:
❑ SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION 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 FLOORDRAINS SHOWER WATERRIPING
BATTiTUB GAS PIPING (NEED QTY LIC) SWIMMING POOL WATER SOFTNER ($3�
CLOTf�S WASHER KTTCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �ATER 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 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 ermit and rk is not to start witho t a permit on site; that the work will be in accordance
with the approved plan in the case of o• �h' e ires review and appr 1 f plan �
SIGNATURE OF APPLICANT PRINT NAME DATE �
APPROVAL INSPECTORS SIGNATIIRE _ �C_ __ _ � DATL
City of Fridley
�uilding Inspections Department
6431 University Avenue NE, Fridley, MN �54;2
763-572-3604
`FAX: 763-502-4977