P - 47348Building PLUMBING Permit No.: �%4
Inspections RESIDENTIAL APPLICATION Received By: ✓VI�_
763-572-3604 CITY OF FRIDLEY vate ��: J U N l 6 2
763-502-4977 FAX EFFECTivE i-i-ao�i
/ dp�iL!'�i (c� �ol�t�:� in�i • fow�
DATE �` I b" 7�l ( YOUR E-MAIL ADDRESS =- �` d� �w -
siTEaDDxESS �i�CY� /"tq��� S� n>F F'n�l,�y ,.y�,a�s 5`�s`y3z
THIS APPLICANT IS: �OWNER ❑CONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
NAME:` VW��K l�ati['�'f�^
ADDRESS: r6�Dl? �"'� /-k�/Z� Sf �� CITY ��,
PHONE: � I L ���� ' Z 00 �
STATE LICENSE #
STATE BOND # _
ADDRESS:
PHONE
❑ SINGLE FAMILY
❑ NEW
❑ TWO FAMILY
�REPLACEMENT
DETAILED DESCRIPTION OF WORK wA'� ��Ne
CITY_
FAX
❑ TOWNHOUSE
EXP DATE
EXP DATE
ATL� "r ��ZIP S�y Z
STATE ZIP
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: ([NDICATE 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)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
DISHWASHER LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
_ WATER METER �OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply far 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 for a e• it and work 's not to start without a permit on site; that the work will be in accordance
with the approved plan in cas of ork hic • ' es review and approval of plans. -.
SIGNATURE OF APPLIC ' PR[NT NAME t�� T DATE G� ^I 6 Z�11
APPROVAL INSPECT U DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
11