P - 44554Building PLUMBING �ermit No.:�11'Jl�-C703�{ 5
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY D °�IAR � ���
763-502-4977 FAX EFFECTIVE 1-1-2011 ��
DATE j�" ��' t� YOUK E-MAIL ADDRESS //i �
S[TE ADDRESS _ 73 (g � rn� �)Y�l.l ` /v � �{`` � � �
THIS APPLICANT IS: ❑ OWNER CONl"RACTOR
PROPERTY NAME: e(� � r�1/�
OWNEW ADDRESS: %� �p � Me �i�. I. Vl 1U�CITY i�
TENANT pHONE:_� 3' 7$�/' I� S�/ �—
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
MSURANCE
PERMIT TYPE
STATE LICENSE #_
STATE BOND # �
ADDRESS: l3s
PHONE CQS/^
�SINGLE FAMILY
TYPE OF WORK: � � xE�'''
DETAILED ESCRIPTION OF WORK
be ��� � ���
ATE ZIP
�. w�, `�ri- L�
S�� '� EXP DATE f� � J- �
5 3 a � EXP DATE
9�U% �iil%t �C�� y, %��j'�✓�� Gfd✓'e.STATE M ZIP 5 5�
3tg F.ax
❑ TWO FAMILY
�REPLACEMENT
❑ TOWNHOUSE
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FlXTURES: (INDICATS TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
_ BATHTUB GAS PIPiNG (NEED CITY LIC) S W[MMING POOL WATER SOFTNER (S35)
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 PERM[T-NOT VALID UNTIL PROCESSbD
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 oniy 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 case o I o k which requires review and approval of lans. 2
SIGNATURE OF APPLICANT �/�- PRINT NAME % � I/
___._ � ��y%�•> / DATE J � �
•----- - ------------���
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977