P - 41401Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
PLUMBING
RESIDENTIAL APPLICATION
❑ OWNER
Permit No.:
Received By:
CITY OF FRIDLEY vate xec'd: "
EFFECTIVE 1-1-2011
YOURB-MAILADDRESS �Q�.t-Y'Gl cJ +'YND��'"�cf�-+~PI/.�rnl.�nq -�
ADDRESS: � Gtr�-2� �S GL�ot1...t�CITY.
PHONB: % �D 3 ^ S ~% f - � 3C7 �
�
CONTRACTOR NAME: t e�� ��.1�2r^ � c.iG¢x�-- �l��b i r� a
SUBMIT A COPY OF STATE LICENSE # �!Q I q'Y 'CJ i�/Y) EXP DATE /�- ^`,3/ -/ a-.
YOUR STATE
LICENSE, BOND AND STATE BOND # d''+ �� Zi EXP DATE
CERTIFICATE OF ADDRESS: `.S�l 2� �/1�I �t �» CITY ,/�» o k� STAT�� zIP J�53 d'
INSURANCE Z�n -� , y-'J, -1 a� SS� p Fax `7 � 3- S 7�- S k�"�'
PHONE
PERMIT TYPE
TYPE OF WORK:
�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
�EPLACEMENT
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL
CLOTHES WASHER KITCHEN SINK �jW"'ATER CLOSET
DISHWASHER _ LAUNDRY TRAY nWATER HEATER ($35)
WATER METER
_ _ _ _
>
4Q.OA1 T
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
WATEIt PIPING
WATER SOFTNER ($35)
� BACKFLOW PREV. ($15)
FOR IRRIGATION
OTHER
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 w' the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and work is not to s without a permit on site; that the work will be in accordance
with the approved plan in the c r whi e ires re ' w d app ov 1 of plans. J
SIGNATURE OF APPLICANT T NAME�� D�Y�C�ICR.Y' DATE �` � I I
APPROVAL INSPECTOR DAT
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
�63-572-3604
FAX: 763-502-4977