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P - 46510Building Inspections 763-572-3604 763-502-4977 FAX DATE `� SITE ADDRESS _ THIS APPLICANT IS: PROPERTY OWNER/ TENANT CONTRACTOR SUBMIT A COPY OF YOUR STATE' LICENSE, BOND AND CERTIFTCATE OF INSURANCE PERMIT TYPE �E oF wo�: ' 1\/ � I\ !' Permit No.: �b� (/� 2 5`7 (p RE SIDENTIAL APPLICATION Received By: /��✓ CITY OF FRIDLEY 'i��: � � ���� EFFECTIVE 1-1-2011 YOUR E-MAIL ADDRESS �� �i� ih 1�1 l�bJ w rn�!!w"1 • i1P�� O �a I,c �P,�.a �-� Vl �_ ❑ OWNER �-�COi NAME: .a,nnxESS: k PHONE: ��Q :7 :�I' �J4 � rraME: b�i �� � STATE LICENSE # �i EXP DATE ��� STATE BOND # EXP DATE ADDRESS: �D� 1'[�l�(1�1'I.OVI�" S�' Y��:. CITY �F'f��ile�Ul STATE J�I'2 ZIP PHONE ~T{�1 �J �G' � 7�iC� FAX B SINGLE FAMILY NEW DETAILED DESCRIPTION OF WORK 0 TWO FAMILY ❑ TOWNHOUSE ❑ REPLACEMENT FEES ARE BASID ON $10.00 PER FIXTURE, EXCEPT WI�RE NOTED. FIXTURFS: (INDICATE TOTAL NUMBER OF EACH BII.OV1�: MINIMUM FEE $35.50. BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING BATHTUB GAS PIPING (NEED CITY LIC) SWIlvIMING POOL WATER SOFTNER ($35) CLOTf�S WASHER KITCHEN SiNK WATER CLOSET BACKFLOW PREV. (S15) _ DISHWASHER _ LAUNDRY TRAY X WATER HEATER ($35) FOR IRRIGATION _ 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 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 pernvt d work is not to start without a permit on site; that the work will be in accordance with the approved plan in the o all � requires review and app�Q��, Q€p �}-�,,,a SIGNAT[JRE OF APPLICANT PRINT NAME s�rJ1(:�1. �� ,(XA DATE __( I�(C�/ I 1 APPROVAL INSPECI'ORS SIGNAT ne� City of Fridley Building Inspections Department 6431 University Avenue NE, Fridley, MN 55432 763-572-3604 FAX. 763-502-4977