P - 43034Building PLUMBING Permit No.� ��r��
Inspections RESIDENTIAL APPLICATION Received By:�
�63-s�2-3604 CITY OF FRIDLEY �
763-502-4977 FAX EFFECTIVE I-1-2011 �������
DATE f0 `"/ Z"�� YOUR E-MAIL ADDRESS
SITE ADDRESS /�C` .�o,v � %� sj-° �(%j=
THTS APPLICANT IS: O OWNER ONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, B�ND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
ADDRESS: %,llo iCtiN��£��tu S''/[/� CITY
PHONE:_� ��-�� Z80- yyof'
NAME: �c i�.¢Cy fC c.s�e,Ps �ff'Li�rLrt
STATE LICENSE # � %�C,
STATE BOND # /.Z� 1 �c5 6
ATE ,iNLI P .3�.�%��
EXP DATE %.Z "3 /�—f Z
EXP DATE
ADDRESS:zZ3 3•9-n��E'b�r� Kr.� CiTY �NtiCFl�b STATE�ZIPS' ��
PFIONE %63- Z/9' tp9%8 FAX __%6 �' Z%S Oro.fY
�INGLE FAMILY
❑ NEW
DETAILED DESCR[PTION OF WORK
0 TWO FAMILY
��'REPLACEMENT
�� Gf/�Tf�Z
� TOWNHOUSE �
�Z
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). M1N(MUM FEE
535.50.
BATN SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
_ BATHTIJB GAS PIPING (NEED CiTY LIC) SWIMMING POOL WATER SOFTNER ($35)
_CLOTHES WASHER KITCHEN SlNK WATER CLOSET BACKFLOW PREV. ($IS)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
TH[S IS AN APPLICATtON 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 app e'o 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 i�cas f al k �quires review and ap al of plans/ /�
SIGNATURE OF APPLICAN�f PRINT NAME 6 `�/ � C,t�.�/' f'r- DATE /D �/ L�//
APPROVALINSPECTORSSIGNATURE _ __ DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977