P - 45739Building PLUMBING Permit No.��� �� I� �
Inspections RESIDENTIAL APPLICATION �te�ei�ed B � '
763-572-3604 # y"
763-502-4977 FAX CITY OF FRIDLEY Dat�o'a� -
EFFECT[VE ]-1-2011
DATE !p' 3CG � I� YQ�T R E-MAtL ADDR6SS �� � l� %i�� ��u''K �' C�''�
SITE ADDRESS � 7�� 7 �-PL"%'� �S'�*n/ �� /vE
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
ce
/J/���sei
ADDRE3S: �177 37 ,� -cF�-e, vS�•.� � VL' CITY -�fZ i pl �P�l STATE ly+�IP
PHONE: C'I SZ 2 z�' S�9SU
(L�/ �t-'lu�tit�
STATE LICENSE # (D%�T�-��i"�°Y1 EXP DATE ���.3/� /Z
STATE BOND # % Z SS %`�� EXP DATE ��/f�� � Z-
ADDRE3S: CO =iG7C� r.S3 ''� �� CITY /2/9�i1 5� �� STATE rn�/ ZIP S� a 3
PHONE C�o !� 2�f S� �$� FAX `
TYPE OF WORK: I� NEW
FAMILY O TWO FAMILY ❑ TOWNHOUSE
DETAILED DESCRIPTION OF WORK
� REPLACEMENT
hy ��v�-1z�
� (� CL i(J °i. f
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED.
$35.50.
✓BATH SINK/LAV FLOOR DRAINS
� BATHTUB GAS PIPING (NEED CITY LIC)
� CLOTHES WASHER KITCHEN SINK
� DISHWASHER LAUNDRY TRAY
r�
FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
� SHOWER
SWIMMING POOL
t-` WATER CLOSET
WATER HEATER ($35)
WATER METER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
WATER PIPING
WATER SOFTNER ($35)
BACKFLOW PREV. ($15)
FOR [RRIGATION
_ OTHER
T 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 Fridtey 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 the ase f all work �i� requires review and approval of plans.
SIGNATURE OF APPLICANT fi PRINTNAME i�6C �S'��1-) DATE � 3 c� � i l
APPROVAL 1NSPECTORS SIGNATURE DATE
City of Fridley
Bu�lding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977