P - 48037Building
Inspections
763-572-3604
763-502-4977 FAX
DA1'E i �7 - 7' ��
SITE ADDRESS �
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMTT A COPY OF
YOUR STATE
L[CENSE, BOND AND
CERTIF[CATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
� PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-201I
�rb� s
O OWNER
rhh �- ,
ai
Permit No.:2�� �02-�`� �
Received By:�_
����e��C � � �01�
YOURE-MAILADDRES3 L Pl�. �7r7�i�n1%, C�E�I�
�CONTRACTOR
, �.����i,,.
ADDRESS: li 5�/S� �Grl�iG S� �G% CITY yt�!I�
PHONE:
ATE �� ZIP�
NAME:_ GL/7�i9/�, V'/vl+��>fr�{ J'/�f��{ TnG
STATE LICENSE #�(�ll�� 3�% I EXP DATE �Z - 3/-��11Z
STATE BOND # P�/�L� S7��p� EXP DATE /Z- 3/ - Zd//
ADDRESS:�G>�G J�3� Sr' /iJ� CITY t� ,ILt� STATE�ZIP�DZ
PHONE G�%Z ' %S %- 5�,� FAX ,3 �-o�G3'"��%
QQSINGLE FAMfLY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
� REPLACEMENT
r
FEES ARE BASED ON $10.00 PER FIXIURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
j�BATH S1NK/LAV FLOOR DRAINS }�SHOWER
BATHTUB AS PIPING (NEED CITY LIC) SWIMMING POOL
CLOTHES WASHER �ITCHEN SiNK WATER CLOSET
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35)
WATER METER
TH[S [S AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
WATER PIPING
_ WATER SOFTNER ($35)
BACKFLOW PREV. ($IS)
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 with the Minnesota Construction Codes; that I understand this is
not a permit but only 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 all w�k'w '�equires review and apprQ �al of pla s.
SIGNATURE OF APPLICA�Fi-�=� _. ,:� PRINT NAME '�.,.,G/���1 j, DATE_I� �%� ��
APPROVALINSPECTORSSIFJIVATURE ' nerc
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977