P - 44543Building � PLUIVIBING � permit Nd.�� ��v ��
Inspections �S��ENT�AL APPLI�ATION Received By: �
�63-s�2-3604 CITY OF Fi2IDLEY Date��: � p�� 2 11
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE l�l (�
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
❑ OWNER
NAME:
ADDRESS: 5^5�;
PHONE:�lr�
NAME: V'�V
STATE LICENSE #_
STATE BOND # _
ADDRESS: Z , D
PHONE ��
�SINGLE FAMILY
TYPE OF WORK: I❑ NEw
DETAILED DESCRIPTION OF WORK
YOUR E-MAIL ADDRESS
CITY� STATF�ZIP,
EXP DATE
EXP DATE
_CITY�,_ STATE ZI
F� � 3-�5 — �,as�
❑ TWO FAMILY O TOWNHOUSE
�REPLACEMENT
�,
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATHSINK/LAV _FLOORDRAINS SHOWER _WATERPIPING
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 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 th ,�j� �e,� f all �,,k� w�hich requires review and approval_of pl /
SIGNATURE OF APPLICANT �� `�"�'�� ��'" rw PRINT NAME /� !U� ��s�' DATE `/ I(�/
APPROVAL INSPECTORS SIGNATURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977