P - 45287� � ���
Building PLUMBING P����: ��" "`-.� d
Inspections RE+ SIDENTIA.L APPLICATION Received By: �
763-572-3604 CITY OF FRIDLEY nate Itec'a: �-.� � �
7b3-502-4977 FAX �FxE��nv� 1-�-za� i 1
DATE � YOUR E-MAIL ADDRESS � l'��?gl.`,� �jG?lX'I�-C�� N` � G'N • C�CJJIM j
sirE nn��ss ° �� 1'l� e jC i r� 1 L?, ,� -�` N C
THIS APPLICANT IS: C] OWNER ONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATB
LICENSE, BOND AND
CERTIRICATE OF
INSURANCE
PERMIT TYPE
AdDRESS:
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...- �'i �i i _ _ 4�.
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srn7 E�acEtvsE #_�(6,,� f") ��i Y 1'a'� �atr nn� 1 Gd ��� I I
STATE BOND # EXP DATE
ADDRESS: 7 CCCY �� IL ��vl.ff-Y� STATE�N ZTP SS3 �!
PII�TJE �[� � p � c� ! "�-� � � �'7 FAX � tc'�7 "� L'S �7 .."_ � ,�3 �
�INGLE FAMILY
TYrE o� wo►�: I� NEW
❑ TWO FAMIL,Y ❑ TOWNtHOUSE
�PLACEMENT
DETAlI.ED DESCRIPTION OF WORK r�Z�l_p�, �_ V�,�C�t�l_-r'' ��d-'�---('
FEFS ARE BASEb ON $10.00 PER F[7CI'URE, EXCEPT WHER6 NOTED. �IXTURES: (INDICATE TOTAL NUMBER OF EACH BELOt�. MCN[MUM FEE
$35.50.
BATH SINK/1<AV FLOOR DRAINS SHOWER WATER PIPING
� BAT};1'UB GAS PIPING (NEID CITY LIC) � SWtMMING PC�L LVATER SOFTNER ($35)
CIAT'I-IES WASHER KITCHEN SMK � WATER CLOSET ^ BACKFLOW PREV. <�StS)
� DISHWASH�R `LAUNDRI' TRAY �WATER HEATER ($35) FOR 1RRIGAT70N
� WATER MbZ ER � OTHIIt
Number Of fixtures @�10.0�D X�I O.QO =$
Number of fi�ctures @�I S.OU x S� 5.00 =$
Number of fiacturex @$35.00 � x 535.00 =$_ rt'�
State Surcharge $ 5.00
� �
�MINIMUM 540.00) Toi�1= $ L
THIS ]S AN APPI.ICATION FOR A PERMIT-NOT VALiD LJN'I1L PROCESSID
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 cudes of the City of Fridley and with the Minnesota Construction Codes; that [ understand this is
not a permit but only an applicatio or a permit and work is not to without a permit on site; that the work will be in accordance
with the approved pian in the case 1 ork �ic qu res revie 'and p at oipi i. 1�,
SIGNATURE OE APPLICANT ,. � , N�E� � �''T DATE —L � � ��
AND
City of Fridley
Building Inspections Department
6431 Univetsity Avenue NE, Fridley, MN 55432
7b3-5'72-3604
FA �: 763-502-49fi7