P - 44545� `.
ti
Building
Inspections
763-572-3604
763-502-4977 FAX
DATE [ Q� �
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 7-I-2010
YOUR E-MAIL ADDRESS
❑ OWNER �CONTRACTOR
Permit No.� �
Received
t� ��'
ATE��IP.
CONTRACTOR N�: Chamnion Pium�ifn
SUBMIT A COPY OF STATE LICENSE # # B'i %%n—PM EXP DATE ��--�, � I �
YOUR STATE
LICENSE, BOND AND STATE BOND # 6�� `.�6rJ-1340 EXP DATE � a- 3�- ��
CERTIFICATE OF ,,,DD�ss: Dodd Rd. CTTY STATE ZIP
INSURANCE pHONE ' FAX
PERMIT TYPE
TYPE OF WORK:
C�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY Q TOWNHOUSE
�PLACEMENT
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FTXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV�. NIINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CTTY LICp SWIIvIMING POOL WATER SOFTNER ($35)
`CLOTI-IES WASHER KTTCHEN SINK WATER CLOSET BACKFLOW PREV. ($IS)
`DISHWASHER _ LAUNDRY TRAY I WATER HEATER ($35) FOR IRRIGATION
_ WATER METER ^ OTHER
THIS IS AN APPLICATION 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 application far a permit and wark is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case o 11 work whi re '� �,review and appr val of plans�s ��� "/1��
SIGNATURE OF APPLICANT � NAME,�i 1PS t"� %YIGi.I-[�Y DATE � � �
APPROVAL INSPECTORS SIGNA �!���J�G���/��a�(�� A� �'`1 I
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
( oo So8 c,P�