P - 44889Building
Inspections
763-572-3604
763-502-4977 FAX
DATE J " -J ! —'
S[TE ADDRESS / '
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
NAME:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECT7VE 1-I-2011
❑ OWNER
YOUR E-MAIL ADDRESS
� Ln.
r
PHONE: �%�03— �%$�o ^-� A' S�s' U
CITY
Permit No.:
i� - -. : �L'.�
-
i�,�:. - `-. ;�, ; �
ATE ZIP.
CONTRACTOR NAME: �Z7� � sE��v E'�C. —� w A"��it..
SUBMIT A COPY OF
YOUR STATE STATE LICENSE # EXP DATE �� 3 �- ad j 1
LICENSE, BOND AND STATE BOND # EXP DATE
CERTIFICATE OF qDDRESS: J UOC� '� i o nee�' i rr.� I CITY [..� �t'� STATE mr, .ZIP �357
INSURANCE pHONE � �D ;3 ~$� 3$ = 3$v 3 FAX
PERMIT TYPE
TYPE OF WORK:
�GLE FAMILY
❑ NEW
❑ TWO FAMILY ❑ TOWNHOUSE
�PLACEMENT
DETAILED DESCRIPTION OF W ORK S ff ��j' o F� r/ /-1 ( u t: S'7'2 �T S' �� 2
FEES ARE BASED ON $]0.00 PER FIXTURE, EXCEPT WHERE NOTED.
$35.50.
BATH SINK/LAV FLOOR DRAINS
BATHTUB GAS PIPING (NEED CITY LIC)
CLOTHES WASHER KITCHEN SINK
DISHWASHER LAUNDRY TRAY
FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
SHOWER
SWIMMING POOI,
WATER CLOSET
WATER HEATER ($35)
WATER METER
WATER PIPING
WATER SOFTNER ($35)
$ACKFLOW PREV. ($15)
� FOR IRRIGATION
� 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 appli ' n 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 t cas of al � ich require review and approval of�lans.
SIGNATURE OF APPLICANT PRINT NAME �b� /,%� U�� DATE 3"' -��-�J
APPROVAL INSPECTORS SIG URE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977