P - 44555Building
Inspections
763-572-3604
763-502-4977 FAX
DATE_ �/ ! id ��
�—
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-20ll
YOURE-MAILADDRESS _ �PS P�i.li"�p; t�
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❑ OWNER e�pNTRA
NAME: `J� �� (Z �
ADDRESS: �tj �o Z Y"� p ;
PHONE: �I Z�� � �K �
CONTRACTOR NAME:��
SUBMIT A COPY OF STATE LICENSE #
YOURSTATE
LICENSE, BOND AND STATE BOND #_
CERTIFICATE OF ADDRESS:
TNSURANCE
PHONE
PERMIT TYPE I� SINGLE FAMILY
TYPE OF WORK: I �EW
DETAILED DESCRIPTION OF WORK
�/��-9� � �6L V / �. hz
❑ TWO FAMILY
❑ REPLACEMENT
TY
Permit No.:r.�
Received By:
�
STATE
Z
EXP DATE i Z- 3I -� J Z-
EXP DATE l Z" y' I— l I
�,S,STATE �/V Zl P�� 1'
_ FAX �
�TOWNHOUSE
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICA'f� TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50. f
� BATH SINK/LAV FLOOR DRAINS / SHOWER WATER P(PTNG
_ BATHTUB GAS PIPiNG (NEED CITY LIC) S WIMMING POOL WATER SOFTNER ($35)
_ CLOTHES WASHER � KITCHEN SINK � WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER LAUNDRY TRAY WATER HEATER ($35) FOR [RRIGATION
� WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing pennit and I acknowfedge 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 appl' ' and wor ' ithout a permit on site; that the work will be in accordance
with the approved plan in e ca o �c requ� revi d approv of pllns. p.��
SIGNATURE OF APPLICAN AM£ �f�'✓L�- ���I%�Fr/�IJATE 3 J / J
APPROVAL INSPECTORS S ATURE ✓ ,�i]l/ naTF /
City tff' Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
7b3-572-3604
FAX: 763-502-4977