P - 37244Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�1
SITE ADDRESS `
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIF[CATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATI4N
CITY OF FRIDLEY
_ EFFECTIVE I•1-201I
t I�; �i�►i
>��L� ���
�OWNER
NAME: i"Y11^
YOUR E-MAIL ADDRESS
�f� �51T N �;.
OCONTRACTpR
C'. .,,.�r
ADDRESS: ��>' %;� r� �I C�.C�k s� 1^l v� �
PHONE: � �c�'>-' � � �-{ -�-�-{-Q �±
NAME
STATE L[CENSE tt
STATE 80ND #
Permit No.:
Received By:
D�.��'��'
�1 �:� � ��d STATF1.Vin,jZ1P 55 y�{Z
ADDRESS: CITY
PHONE FAX
SINGLE FAMILY
❑ NEW
❑ TWO FAMILY � TOWNHQUSE
�REPI.ACEMENT
EXP DATE
EXP DATE
ATE Z(P
DETAILED DESCR[PTION OF WORK rP m€?�i - �,hav��r� n� �} f� r�plcz.C� ��p oy�L v�, ��oi ��f' �
�„ .,; �, . w � r � �-. ., . , ,. � ,. : .� . .. �._ .. , _. _. _. .� ---
FEES ARE BASED ON $10.00 PER FiXTURE, EXCEPT WHERE NOTED. FIXTURES: ((NDICATE TdTAL NUMBER OF' EACH BBLOW). �11N(MUM FEE
$35.50.
Li BATH SINK/LAV FLOOR DRAINS X SHOWER WATER PIPING
_ BATHTUB _ GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
_CLOTHES WASHER KITCHEN SIt�K WATER CLOSET BACKFLOW PREV. ($IS)
` D[SHWASHER ^ LAUNDRY TRAY �WATER HEATER ($35) FOR [RRIGAT(ON
_ WATEA METER OTHER
THIS [S 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 wi11 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 th case f al) wor�+ �w�hich require� review and approvai o1.�f plans, f
SIGNATURE OF APPUCAN7���. �ZL'�L t�l.���.� pRINT NAME �lt't, S`J�iCli1SC i 1 DATE �/ ��"I ( l
APPROVAL INSPECTORS SIGNATURE nn-rc
City of Fridley
Building Inspections Department
6431 University Avenue NE, Friclley, MN 55432
763-572-3604
FAX: 763-502-4977