P - 48110Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ��I �� � I
SITEADDRESS (4JZ(p
THIS APPLICANT IS:
PROPERTY NP
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-1-2011
YOUR E-MAIL ADDRESS
0
ENNAN,�i, ADDRESS: ��/Z�p �Gj�/�+Fr��E CITY,
Permit No.:' L�� j'C1�? V� c
Received By: �
� 4te�� 0 �
STATF.�'N�7_iPW �
PHONE: �3"✓ � � (i/�fD
CONTRACTOR NAME: K-1 V G � I
SUBMTI' A COPY OF
YOUR STATE STATE LICENSE �! EXP DATE
LICENSE, BOND AND STATE BONQD� # EXP DATE
CERTIFICATE OF ADDRESS: D G- ! D l�' �n q�1�1, 1�I � Y��� CITY �iI ST(AJTE ZIP � ? 2
INSURANCE pHON.E � '1 '' �4 � !�l'Z�I FAX S � ��V3
PERNIIT TYPE SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW �REPLACEMENT
DETAILED DESCRIPTION OF WORK
FEES ARE BASED ON $]0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL I3UMBER 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 WATERCLOSET BACKFI.OW 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 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 Conshuction Codes; that I understand this is
not a permit but only an application for� rmit an work is not to start without a permit on site; that the work will be in accordance
with the approved plan in th se f al��� •k\ hi �J�equires review and approv ��/f! plans�� ../�� C�
SIGNATURE OF APPLICANT ��� �" ""i'J'���! ._ PRINT NAME /��I Nt J/ �i' DATE ✓
APPROVAL INSPECTORS SIGNATURE ' DATE
� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley; MN 55432
763-572-3604
FAX: 763-502-4977