P - 42133Building
Inspections
763-572-3604
763-502-4977 FAX
DATE (o U�.�' ob!
SITE ADDRESS J y�'I a
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
L[CENSE, BOND AND
CERTIFICATE OF
INSl1RANCE
PERMIT TYPE
PLUMBING Permit No.: ZC� �j ��
RESIDENTIAL APPLICATION Received By:M
CITY OF FRIDLEY � ��: ' �r
EFFECTIVE I-I-201I
YOURE-MAILADDRESS �� @,,/ P�KM�i.. L�.�GdNn1I ��-
1 �...L_ n\ ..r `�
❑ OWNER I�ICVNTRACTOR
ADDRESS: e2 G cY� O ,� N�
�.,..-
__��SQU� �' STATE�r✓L1P�1%3
STATE LICENSE # (01 �� I A yv� J EXP DATE � J OQ G C�}O r I
STATE BOND #� I S�� EXP DATE � � �Ca. aC)) (
ADDRESS:_ LOS �� ���i�' G}w CtTY SA't?G4e+4 STATE I'�ZIP�
PHONE�� d- l(�(' Ifn �i-'S� FAX � 9� oZ N�I % `�7 eZT
TYPE OF WORK: � o►vEw
FAMILY O TWO FAMILY
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE ��� ( (
�
�
��a 3� �r�.� �
PEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. f1XTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MiNfMUM FEE
E35.50.
:L BATH SINK/LAV FLOOR DRAINS SHOW ER
1 BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL
CLOTHES WASHER KITCHEN SlNK 1 WATER CLOSET
_ DISHWASHER _ LAUNDRY TRAY WATER NEATER (S35)
WATER METER
TH[S IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
WATER PIP(NG
WAT�R SOFTNER (E35)
BACKFLOW PREV. ($IS)
FOR IRR(GATtON
OTHER
I hereby apply for a plumbing permit and T 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 1 understand this is
not a pecmit but only an application for a permit and work is not to start without a permit on site; that the work wiil be in accordance
with the approved plan in the e of all w r which equires review and appro 1 of ptans.
SIGNATURE OF APPLICANT ��T��� i� � PRINT NAME �'�r''� �/ . S��z Z�,QATE 7 OGa a O i I
.�....,..... �...........,......,.T�_._ ,.
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977