P - 39777Building
Inspections
763-572-3604
763-502-4977 FAX
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
Permit No.:��
Received By: �rY�
Date �: � �"' � '"
DATE � C� '2 q—�� YOUR E-MAIL ADDRESS �_�'�, ,�5 I� Q L�( C75
SITEADDRESS � . 75,3 ��-{ ( � L �.-•'�(`e—
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
�CONTRACTOR
NAME: L- I-► � I-� ,u �..� ��r-7 d- � r�a�.� �
aDDxESS: 7�� 3 �- �! r�� L�.✓� �, CITY,
PHONE: � (.O� - `� Z'i J -- � � 1.�5
STATE LICENSE #
STATE BOND #
ADDRESS: CITY_
PHONE FAX
�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION( 'O+�F WORK
''�, n r� ✓A -�[� -C,�' 1,
❑ TWO FAMILY
�EPLACEMENT
�a c�, ��.�. n
O TOWNHOUSE
� f'c.1�
STAT�,�ZIR.�� Z
EXP DATE
EXP DATE
STATE Z1P
� c��2.5h
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER (�35)
CIATHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
1�ISHWASHER LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
� WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCES3ED
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 ap lication 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 t a o all e ires iew and appr a�-Qf�?1 S.,�.!, �1. 1
SIGNATURE OF APPLICANT RINT NAME � C� �.7�aG1V Y� C�'' _ DATE ���' �_! " lU
APPROVAL INSPECTORS SIGNA _��� Lrr. nc.w/�
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977