P - 60360Building PLUMBING Permit r1o.: 2�04
Inspections RESIDENTIAL APPLICATION Received By: l�
763-572-3604 CITY OF FRIDLEY Date Re�'d: l �—
763-502-4977 FAX EFFECTivE �-�-zo�z
DATE `I j I Z � YOUR E-MA/IL ADDRESS fCL�L�i� �� � e� CJd
SITE ADDRESS (pll� �,/,(ftS � \�(� 5 / /LG il.�(C � , �'Ivi ' �7 �13�
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY Nntv1E: �'1 G f� �y�
OWNER/ ADDRESS: ll� (/J��S l/l�GG �7 /(� C[TY f STATL��1 ZIP y3a
TENANT pHONE: �l0 7 2,� Z-� 7�3
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE STATE LICENSE # EXP DATE
LICENSE, BOND AND STATE BOND # EXP DATE
CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE
PHONE FAX
PERMIT TYPE �INGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: "' N�W ❑ REPLACEMENT
DETA[LED DESCRIPTION OF WORK �{,�:,� ��V`� i� �i�,rxc ✓�
FEES ARE BASED ON $] 0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FF.E
$35.50,
�BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB _ GAS PIPING (NEED CITY LIC) �IMMING POOL _ WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET ` BACKFLOW PREV. ($15)
DISHWASHER LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
Number of �ixtures � $1D,0� � �c $1Q.QQ= � �
l�urnb�r vf �ixtur�s �,ia $15:00 ° � �. � $1 S,aU�'�� _ $
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Number af fixtur�s c�i �3S,�Q �x $3S:OCM''� �k---=y--�— ; y �i �) , � � , i .
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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 f the ' of Fridley and with the Minnesota Construction Codes; that 1 understand this is
not a permit but only an application for a per it d ork is not to start without a permit on site; that the work will be in accordance
with the approved plan in case o a I rk w' h equires review and appro al of plans. /
SIGNATURE OF APPLICAN PRINT NAME I�e•°+ ��C'h�,� DATE y i 3 % Z
APPROVALINSPECTORSS GNATURE DAT
PL��s� rra�� s�pa���-��t�z�s uz�� �oR ��zz�����,��;�c°r�z.te�;L �a�r� �� w�
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977