P - 40740Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTlVE 1-t-2011
DATE ' / '
SITE ADDRESS �` C� ✓� r-+ 1� E7
THfS APPLICAtJT IS: � OWNER C�
YOUR E-MAIL AbDRESS ��� � b �' �
�
Permit No.
Received By: / �'� L
Date R��. e� 2 Q� 1
PROPERTY NAME: L��, S C cti
OWNER/ pDDRESS: I��� �✓1 ��c�t o CITY r �
TENANT �/ � � e y STATE�ZiP
PHONE: ' [Yj S � � � - � �^/12j � �
CONTRACTOR NAME: M� �� I N�^^�'^� a� CC'd �7 a``t-
SUBMIT A COPY OF STATE LICENSE # Ci G� ���(" � EXP DATE
YDUR STATE
L[CENSE, BOND AND STATE BOND �_���� LU a�� &XP DATE
CBRTIFICATE OF ADDRESS: � 3�� %� CtTY
INSURANCE �� �=�� � STATE M� ZIp S�� °�
PHONE FAX
PERMIT TYPE I �SfNGLE FAMILY
TYPE OF WORK: � O NEW
DETAILED DESCR[PTION OF WORK
0 TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
�CBATH S1NK/LAV FLOOR DRAfNS SHOWER WATER PiPING
� BATHTUB _GAS P(PING (NEED CiTY LIC) SWfMMING POOL WATER SOFTNER ($35)
_CLOTHES WASHER KITCHETJ SiNK � WATER CLOSET BACKFLOW PREV. {$15)
, DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) � FOR IRRIGATION
_ WATER METER OTHER
TH[S 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 wili 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 permit but only an applic n f r 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 of ork which requires review and approval o�I� lans. r S
SlGNATURE OF APPLICANT � PR1NT NAME �(� t\ ��� DATE �� � l l I `
APPROVAL INSPECTORS SIGN I R. 1lATC
City of Frid[ey
Bui�ding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977