P - 36950Building PLUMBING PermitNo.:� `J3
Inspections RESIDENTIAL APPLICATION Received B
763-572-3604 CITY OF FRIDLEY Da 'd ' �
763-542-4977 FAX EFFECTIVE 1-I-2011 ���
DATE �� � �7�` / [ YOURE-MAILADDRESS �i-(��I�� �✓LL�GJ ' 1 vL.�"v✓�
SITE ADDRE55 i r � fi
THIS APPLICANT IS, Z..�� ❑ OWNER �ONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
ADDRESS: J � � -� � r CtTY
PHONE:
ATE
S7ATE LICENS�#__Cj,-f���� -� EXP DATE 1 �i % - / �'� �Z
STATE BOND #.�c�O �� � S�(:� � 9y� EXP DATE �' �^��
ADDRESS: O IvI i ,4 �. � ( J_CITY � STATE�[�ZIP�
PHONE_� J 7 � � I� FAX
PERMIT TYPE �SINGLE FAMILY ❑ TWO FAMILY p TOWNHOUSE
TYPE OF WORK: I� NEW ,0 REPLACEMENT
1 �
DETAILED DESCRIPTION OF WORK CCS (' Y��` (,. )���''� G�.✓l � t.��'I �� rr1G5 ,.,i- S� �' ,.Y �tJ
FEES ARE BASED ON $10.00 PER FIXT'URE, EXCEPT WHERE NOTED. FIXNRES: (INDICATE TOTAL NUMBER OF EACH BELOW). MiNIMUM FEE
$35.SQ
� BATH SINK/LAV _FLOOR DRAINS � SHOWER WATER PlPING
� BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL � WATER SOF7TJER ($35)
CLOTHES WASHER � KITCHEN SINK � WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER � LAUNDRY TRAY WATER HEA7'ER ($35) � FOR IRRIGATION
W ATER METER OT'HER
THIS IS AN APPLICATION FOR A PE2MIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing pennit and I acknowle ge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the C� y of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applic i n for a permit d work is not to start without a permit on site; that the work wil] be in accordance
with the approved plan in the c of ork w'ch requires review and appro al qf plan
SIGNATURE OF APPLICANT PRINT NAME ��VI•Y�, �rt2l.�.�� DATE G�=�G� - Il
APPROVALINSPECTORSSIGN E DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977