P - 44824�
Building PLUMBING Permit Na.:a'� �����
Inspections RESIDENTIAL APPLICATION Received By:�
763-572-3644 CITY OF FRIDLEY D °d
763-502-4977 FAX EFFECTIVE t-1-2�11 �� `����
DATE �� L
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER!
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
YOUR E-MA1L ADDRESS f V'� wl t
�'I Y.� 10� ��� �1-5
❑CONTRACTOR
NAME: _�; pri I'r11'e� � V�GV��In �`iG�Y �S
ADDRESS: h7 M LSSt 651 Yt �'Jt S�• �� CITY I� �' �
pHONE: � c� � a� a�� �-5
STATE LICENSE # EXP DATE
STATE BOND # EXP DATE
ADDRESS: CITY
PHONE FAX
�NGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: I� N�w
DETAILED DESCRIPTION OF WORK
�$EPLACEMENT
�lh
�CG�S �h- n �°
ATE�ZIP �=L7�� o�
STATE ZIP.
� �, .
ti
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 �WATER PIPING
_ BATHTUB GAS PIPiNG (NEED CITY L!C) _ SW[MMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY ^WA'fER HEATER ($35) FOR (RRIGATION
_ 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 f the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a it and work is not to start without a permit on site; that the work will be in accordance
with the a roved lan in �> a e o all r which re uires review and a r val of lans / (
SIGNATU EOFAPPLICAN ` a PRINTNAME �ii�'�}Ylp`� L- `���5 DATE l IG I( `
APPROVAL INSPECTORS SIG URE naTF
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977