P - 35216Building
Inspections
763-572-3604
763-502-4977 FAX
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
-i-2oi�
Permit No.:�
Received By. 1�.�`
Date Rec'd�'���
DATE 7 � 7' �� YOUR E-MAIL ADDRESS � +C%v� C�r %�i�l"� ���%�� �J � �^ `I � �-'% �'L'�-
SITE ADDRESS �u �1 3� .) � S�'�- Sr
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
NAME:
ADDRESS: � 7� 7 �� F� r� +i'S c�t�i CITY f"J"�' t Y� � t`'l STATE YHaJZIP
PHONE: � S"Z— � Z-�= S`�S 2�'
NAME: (`-' w. � 1 k V�.L .
STATE LICENSE # ___� %�'3it� r�� _ __ EXP DATE r Z � i
STATE BOND # EXP DATE
ADDRESS: Ct� �Jia � �S-,3'�p Z-%� N"`� CITY R l°��"^�ii2 `'� STATE N"N Z[P� S
PHONE C► i'2- 2 4� S 7Z S� FAX ''
�jtSINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW �3 REPLACEMENT
DETAILED pESCRIPTION OF WORK z�. �r To G�... Q� o
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH B W). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER ATER PIPING
BATHTUB 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
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 f r a per ' a d o'°is not to start without a permit on site; that the work will be in accordance
with the approved plan in • e e of wor w' e ui rev'ew and approval of plans.
SIGNATURE OF APPLICANT RINT NAME DATE �-�yC
APPROVAL INSPECTORS SIG T RE /„� , QATE--;i�%�'1 %,
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977