P - 40739Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � i,�U
SITE ADDRESS �
THIS APPLICANT 7S:
PROPERTY
OWNER/
TEIVANT
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-?010
❑ OWNER
ADDRESS:
� YOUR E-MAIL A�DpDRESS �
�'1 �i Y' /� '
�CONFRACTOR
(> l�.e -r I rri _1 i- /V CITY
����o
Permit No.:
Received By: ���'
D��������� �a
�e�
ATE�ZIP���
CONTRACTOR NAME: �Vy� � ['}t �o„Qn �' or--•
SUBMIT A COPY OF STATE LICENSE # EXP DATE (
YOUR STATE �- � �- � ��
LICENSE, BOND AND STATE BOND u EXP DATE
CERTIFICATE OF ADDRESS: .J� ( C1TY� ���(� STAT Ztp
INSURANCE PNONE %I03- S%�- "�'�Cl FAX�.� -�'7'�t-• �ST tI
PERMIT TYPE
TYPE OF WORK:
❑ S[NGLE FAMILY
❑ NEW
❑ TWO FAMILY /�TOWNHOUSE
L�CEPLACEMENT
DETAILED DESCRIPTION OF WORK IU�(JIIVI W fJ�'��r' � l r�,�
FEES ARE BASED ON �10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIX7'URES: (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 S1NK WATER CLOSET
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER (S35)
WATEft MET�R
I) T
THIS !S AN APPL]CATION FOR A PERMIT-NOT VAL1D UNT1L PROCESSED
WATEit PIPING
WATER SOFTNER ($35)
BACKFLOW PREV. ($15)
FOR fRRIGATION
_ OTHER
I hereby appIy 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 Ciry of Fridiey and with the Minnesota Construction Codes; that I understand this is
not a permit but only an appiication 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 ca 1 k�h re �res review and apR �val of lans. �t
SIGNATURE OF APPLICANT ���i}��--_ PRiNT NAME fQY� �i►�yYa o�- DATE "t - a0- I l
APPROVAL INSPECTORS S1G 1' T�
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977