P - 44198aBuilding PLUMBING Permit Ivo::��' �� ��
Inspections RESIDENTIAL APPLICATION Received By: �
�63-s�2-�604 � CITY OF FRIDLEY vate Rec'ct: ��
763-502-4977 FAX EFFECTIVE 2-19-09
DATE `� Z�%' C� YOUR E-MAIL ADDRESS
SITE ADDRESS '"j �/O 0 �(L!/1 � �p S�
THIS APPLICANT [S: ❑ OWNER [�CONTRACTOR
PROPERTY NAME: C N 0 ee � S �� a/� .E „" R 1 L� �� K 1���
OWNEW ADDRESS: i,3U �± �K (-'� y I�" CITY ���� ��� t y STAT��A`' ZIP s,1"�!3 L
TENANT
PHONE:
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CONTRACTOR NAME:_
SUBMIT A COPY OF STATE LI( Terry Overacker Plumbing Inc EXP DATE '
YOUR STATE 502 E Main St
LICENSE, BOND AND STATE BO EXP DATE
CERTIFICATE OF pDDRESS �oka, MN 55303 STATE ZIP
INSURANCE pHONE (763) 572-8880 ,X
PERMIT T'YPE � SINGLE FAMILY � TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW �PLACEMENT
DETAILED DESCRIPTION OF WORK �4,L,,a.P.�t.�t_ Lc1 a�.t.c,r X.���
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (IND[CATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS P[PING (NEED CiTY LIC) SWIMMING POOL WATER SOFTNER ($35)
_CLOTHES WASHER KITCHEN SINK WATERCLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
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THIS IS AN APPLICAT[ON 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 case of all work which requires review and approval of plans.
SIGNATURE OF APPLICANT � PRINT NAME V R CI'�. : k k'-� R%� DATE a( Z U�V �)
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City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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