P - 44822Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�� '_�'�_"=� �
SI'TE ADDRESS �
THIS APPLICAN'I' IS:
PROPERTY N�:
OWNER/ �D�;
TENANT
PHONE:
. � ���� �
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
E-MAIL
❑ OWNER 1�CONTRACTOR
.- ,
QTY
pe�it
Received By� ��
Date ��'�� � � � � �
t..yl\li\A�..LVl\ NAME: flt�/T�:/��%vl '�' r l�/"!''�i'G �
SUBMIT A COPY OF gTATE LICENSE # Q 5 �f' ��' —� /� %'� EXP DATE /UA m� e4 �
YOUR STATE � � --Y
LICENSE, Borm AtaD sTn� sorm # 1�7 7 7� a8 � DA�_ ��v,b d� y.e �r
CERTIFICATE OF �DRESS: �f S/G+q7 �%G�S �Ij/�CITY �—STaTF�_Z�/�i
INSURANCE PHONE %C� 3 ' �L I � ��� FAX �/. � '' ' �� g '�
PERMIT TYPE
TYPE OF WORK
(�SINGLE FAMILY
i�NEW
DETAILED DESCRIPTION OF WORK
O TWO FAMILY � TOWNHOUSE
O REPLACE.MENf
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WFIERE NOTED. FIXNRES: {IIQDICATE TOTAL N[JMBER OF EACH BELOVi�. MINAZfJM FEE
535.50.
BATH SINK/LAV PLOOR DRAINS SHOWER WATER PIPIIJG
_ BATITf[JB �AS PIPING (NEED CTTY LIC) ` SWIlI�IIIVG POOL WATER SOFTNIIt (T35)
CLO'fFIE5 WASHER KTfGHEN SIIJIC � WATER CLOSET BACI�I.OW PREV. (S15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER (S35) FOR IRRIGATION
� WATF..R METER OTEIER
2r��3be�c' Of t"i2tti]Ie3 � �IS.{)U x $15.0(1= $
Nwnber of �i�ctures � $35.00 x $35.E� _ $
State Surch�rge o� $ .50 �w
(I4Z�IIMUM� Tota1= S 1 "
THIS IS AN APPLICATION F012 A PERMIT-NOT VALID UNTII. 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 Pridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit atxi work is not to start without a permit on site; that the work will be in accordance
with the approved plan in se of all ork which requires review and approval of plans.
SIGNATURE OF APPLICANT � PRINT NAME�K.t1,L- E�� N l� DATE �� �"�v
City of Fridley
Building �ns�ctions Deparhnent
6431 University Avenue NE, Fridley, MN 55432
� 763-572-3604
FA,X: ?63-502�497'i