P - 47293Building PLUNIBING Permit rto.�L61�v_��
Inspections RESIDENTIAL APPLICATION Received By:�_
763-572-3604 CITY OF FRIDLEY ����e����� �
763-502-4977 FAX EFFECTTVE i-i-aoii
DATE � I � YOURE-MAIL ADDRESS ���C��C�C�j,t;i�� (�YVIA�II�/1c1 %✓� n� C� M
STl'E ADDRESS � �-% �� !Y� �j (°-�-�.�/ 1�- C�
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY NpME: �(], �j Lqi�- �- j �j10 i�/l� S f�:'�
owNE�t/ .�nn�ss:_ �U $,.�. (Y�i� }=�� ,2..� ci� �y� c� 1..2-� sTA�l�z�r
TENANT -
PHONE:
CONTRACTOR NAME: C.i, ?' (��U V1 �
SUBMIT A COPY OF STATE LICENSE # ��3 �/y'� EXP DATE ) vZ - 3 I- o�-L� I�.,
YOUR STATE c�`
LICENSE, BOND AND STATE BOND #� I�J O j l� �`'t � EXP DATE �—� —� ��,
CERTIFICATE OF __S� I �,�,3 �? ,L�N� f�,l,v CITY� ()o � QC".�f�� l�) STATFQ��i ZIP�
ADDRESS:
INSURANCE PHONE ���I � O�J''1 S`�1— �� C`7 FAX �� 5 �I' (� D�GtlJ
PERMIT T'YPE INGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � �W PLACEMENT
DETAILED DESCRIP'TION OF WORK "�� �--�; 11 L--tD Cj GQ. �� 0�,-1 qa f iJJ� �--�� Y�t��,�-�'�.�'
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURE3: (INDICATE TOTAL NUMBER OF EACH BELOV�. MINIMUM FEE
$35.50.
BATH SINK/LAV _FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIIvIl�IING POOL WATER SOFTNER ($35)
_ CLOTF�S WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
Number of fixtures (a7 $10.00 x $10.00 = $
Number of fixtures @ $15.00 x $15.00 = $
Number of fi�ctures @$35.00 � x$35.00 =$.� 5. U U
State Surcharge $ 5.00
$40.00 Tota1= $ �� , � �
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 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 the c e of a11 workp w��hic�h requires review and appr f plans.
SIGNATURE OF APPLICANT ���• ,-r6c{.,v � ��j�—r---PRINT NAME Q��.__, DATE I, � l�' � I I
APPROVAL INSPECTORS SIGNATUR�E / DATE
PLEASE NOTE: SEPARATE PERMITS ARE RE UIRED FOR BiJII..i?ING, ELECTRICAL AND MECHANICAL WORK
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN SS432
763-572-3604
FAX: 763-502-4977