P - 48568Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �'j ` „,L -
SITE ADDRESS 6
TFiIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2012
.-� 2- 5 �1
❑ OWNER
YOUR E-MAIL ADDRESS
s� tl L
.�CONTR.ACTOR
�c� l� —�Z�
Permit No.:
Received By:
Date Rec' d: - —
NAME:
ADDRESS: CITY STATE ZIP
PHONE:
CONTRACTOR NAME: `( 2 ir Sts��.`� �( J nn �,., v
SUBMIT A COPY OF STATE LICENSE # C l�Z I I '" P M EXP DATE f ai -_� �i -�
YOUR STATE
LICENSE, BOND AND STATE BOND # EXP DATE
CERTIFICATE OF ADDRESS: ���i � 3 3 � A�% G n� CITY [ c�w� (D r ��c� L STATE �'"l�Y _ZIP S.SDO �
INSURANCE pHONE '� C�'� 3 S"' �� 70 3 FAX
PERMIT TYPE
TYPE OF WORK:
DETAILED DES�RI
�SINGLE FAMILY
�I.rrEw
FEES ARE BASED ON $]0.00
$35.50.
I BATH SINK/LAV
= BATHTUB
CLOTf�S WASHER
DISHWASHER
OF.
O TWO FAMILY
❑ REPLACEMENT
, �, � ; r, �v I
❑ TOWNHOUSE
a.
EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL
FLOOR DRAINS
GAS PIPING (NEED CITY LIC)
KITCHEN SINK
LAUNDRY TRAY
SHOWER
SWIMMING POOL
= WATER CLOSET
WATER HEATER ($35)
_ WATER METER
OF EACH BELOW). MINIMUM FEE
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
WATER PIPING
WATER SOFTNER ($35)
BACKFLOW PREV. (SIS)
FOR IRRIGATION
_ OTE�R
I hereby apply for a plumbing permit and I acknowle e that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes f the Ci of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a pe it an 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 al�l w\ork 'ch equires review and approval of plans.
SIGNATURE OF APPLICANT 1Ml � W , 2__ �RINT NAME 1M .�� �� ���s i DATE S� ` Z' I"L
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977