P - 36949, ,. , . "� `�_ _ ,� . ��„ , , , v, , �` From;y952-941;1967 � Pa�e: 3/8 � y Date: 4/25/2011 8:34:24 AMv` y �
Building PLUMBING
Inspections RESIDENTIAL APPLICATIUN
�6�-572-3604 CITY 4F FRIDLEY
763-502-4977 FAX HFFECTIVE I•I-2011
DATE��
SITE ADDRESS �
THI5 APPUCANT 15
owrv�w
TENANT
CONTRACTOR
SU6MIT A C�PY OF
YOUR STATE
L1C�NSE, BOND AND
CERTIFlCATG OF
INSURANCE
PERMIT TYPE
O OWNEt
1VAME:__�
ADDRESS: '
PHONE:
NAME;�
STATE I.ICENSE t�_
STATE BOND N
ADDR6SS:,�
PHONB��
�SINCLB PAiNlLY
TYPE OF WORK: I� N�W
DETAILED DESCRIPTION OF WORK
YOUR E-MAIL ADDRESS
�ONTRACTOR
O TWO FAMILY
�(REPLACEMENT
Perni it N
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EXP DATE
EXP DATE �
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C(TY�, STA
_,,,� FAX r
O TOWNHOUSG
FEES ARE BASED ON 510.00 PBR FIXTURE, EXCEPT WHERE NpT�D. FIX7URES: (INDICATE TOTAL NUMBER OF EACW BL•LOW). MINIMUM FEE
$35.50.
BATH SINK/1.AY F1,00R RRAINS SHOWER WATERPIPIiVG
_ 9ATH1iJB _GAS PIPINC (TJEED C.,1'1'V I.IC) "' SWiMMING POf_3L � WA7'ER SOFTNER (S35}
_ CLOTHES WASHER KITCH$N S[NK � WATER CLOSET _�ACKFLOW PREV. ($15)
� DISHWASH�R ,_ 4AUNDRY TRAY '�WATER HBATGR (S35) t"OR IRRIGA770N
,,,� WATf�'R METER _ OTHEIt
Nw�►tt.6er of#ixttit+�.(� S1 O.�f �.,� x$�O:bq �$:,,-„�,,..�.
Nurr�#�er o�`fiixtW� i� S l5;()A .. .. .... t� S'C�,Ob ���,�
NuAabor u� tixtnres � $3�;4Q ' � x �'3S.b(t = $w,���
Stato Surchar�a _.►, x,:.�,b0,�
�
"I7il FQR A PERMIT-NOT VA41D UNTIL PROGE336D
l heraby apply for a plumbing pecmit and I acknowledge that the information above is oomplete and accuratc; that the work wiil be in
conformance with the ordinances and es of the City af Fridley and with the Minnesota Construction Godes; that C understand this is
not a pecmit but only an apptication o a d is not to start without a permit on site; that the work will be in a cordance
with the approved plan in tht case I w review and approv of{� �Js �{
SJGNA1URE OF APPLICANT RIIV'!' AtAME ��„[/ �!G���pATE "T
APPROVALINSPECfORSS1CNATURE r IIATF
`" City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX; 763-502-4977 �