P - 48596Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �� .:> �� ( IZ
SITE ADDRESS �
TH1S APPLICANT IS
PROPERTY
OWNER/
TENANT
PLUMBING Permit No.�" � � �i� �C:�
RESIDENTIAL APPLICATION Received B : �'�`1 ,
CITY OF FRIDLEY �t��e�'*�����,
EFFECTTVE 1-1-2012
YOUR E-MAIL ADDRESS I L�� �,t ���� ��� C�%y�CCX S� I'lf'_ ""�"
� �, 5--t �� � -��cl le v, a��1N �'�� � �.�2
,`� OWNER ❑CONTRACTOR
NAME: � � \ � \L.l: E�. �!1 �-�`.' 1'^
ADDRESS: ��'�L? �1r�'lY�t"��(i Sfi �i�. CITY Y�V�C`��-✓� STAT��'�k��LIPS��"J�
PHONE: �� C � " � -I 2- - ��j 2 �
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE STATE LICENSE #
LICENSE, BOND AND STATE BOND #_
CERTIFICATE OF ADDRESS:
INSURANCE
PHONE
PERMIT TYPE
TYPE OF WORK:
��SINGLE FAMILY
❑ NEW
❑ TWO FAMILY
�PLACEMENT
EXP DATE
EXP DATE
CITY STATE ZIP
FAX
❑ TOWNHOUSE
DETAILED DESCRIPTION OF WORK ����V` -� �%�,)� Ci. l� Vllt t V 1��
FEES ARE BASED ON $]0.00 PER FIXNRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELQW). MINIMUM FEE
$35.50.
BATH SWK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHT[JB 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
� , �
Nur�iber of fsctures � �10.0(3 _� x $10.40 = $
Number of fzxtures �; filS.Q� x$15..fl0 =�
I hereby apply for a pluml�
conformance with the ordi�
not a permit but only an a
with the approved plan in tt
SIGNATURE OF APPLICANT
APPROVAL INSPECTORS SI(
� . 5.ut�
Total = � ° r....�--"
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
permit and I acknowledge that the information above is complete and accurate; that the work will be in
es and code� of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
:a io� £o a�e it^an� w�rk is not to start without a permit on site; that the work will be in accordance
� o a�l o�c hi h �qu} res review and appr 1p s �° � � 1
� ���.i� �`�.. � v PRINT NAME ��� \ � Il. � DATE / C l�
�
�URE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977