P - 46956Building P�,�j�$�N(i PermitNo.:Lbl�*'� ���
Inspections RESIDEN�'I�.� �,FPLI�A�'ION Re�ei�ed By:�i�
763-572-3604 ����� �� ����E�
763-502-4977 FAX EFFECTivEi-�-zon � ���
DATE � � �( � � �
SITE ADDRESS � �D
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMTT TYPE
`YOUR E-MAIL ADDRESS
1�
❑ OWNER �CO
NAME: 1 �'vI't� Ii
ADDRESS: L7 G�
PHONE: � ' .� �G
NAME: I
STATE LICENSE #
STATE BON �
ADDRESS: V
PHONE u.i" �.J�-1'
TYPE OF WORK: ( � NEw
FAMILY
DETAILED DESCRIPTION OF WORK
CITY
❑ TWO FAMILY
�REPLACEMENT
.�
❑ TOWNHOUSE
EXP DATE
EXP DATE
STATE�ZI Z
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 WATERPIPING
BATHTUB GAS PIPING (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
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 permit and wark is not to start without a permit on site; that the work will be in accordance
with the approved plan in th �ti,/f� 11 w which requires review and appro c�f lans� �� �
SIGNATURE OF APPLICANT �'���2"'v'` �� PRINT NAME�L�c.. � DATE i
APPROVAL INSPECTORS STGNA -� DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977