P - 48008Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �� ' L ` � �
SITE ADDRESS _�
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
_ PERNIIT TYPE
TYPE OF WORK:
NAME:
����}�i���i
�SIDEN'�"IA�.... AP�LI��"�'ION
���� o� g'i�����
EFFECTIVE 1-1-2011
❑ OWNER
YOUR E-MAIL ADDRESS _
. �i �' t"�IQ.. I
Ye.,�1.!"'f
Permit N
Received B•
� r'
�e��e'd:
ADDRESS: \ � r �l LiI �-L J� NF CITY Fl�I 1�( � STAT�IN ZIP.
PHONE:� �3• S �1 '► � � �- u
�
STATE LICENSE
EXP DATE
STATE BOND # EXP DATE
ADDRESS: /� 01-9 O � 8-l"� �'fr Ne CITY F{2.-eeo C STATE M`� ZIP.
PHONE FAX
C[ SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ 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.
BATH SINK/I,AV FLOOR DRAINS SHOWER _ WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL _ WATER SOFTNER ($35)
CLOTHES WASHER HITCHEN SINK WATER CLOSET _ BACKFLOW PREV. ($15)
DISFiWASHER LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
— WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROC�SSED
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 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 c Pf all worlc wi� equires review and appro 1 of plans. /�
SIGNATURE OF APPLICANT �`�'� "a � F�iW /J PRINT NAME ��J►-�J I'C,cn P DATE L a� 6- ��
APPROVAL INSPECTORS SIGNATURE _ � � �—DAT�
City oi �'ridley
�uilding Inspections �%iepartment
6431 University Avenue NE, Fridley; MN �5432
763-572-3604
FAX: 76�-502-4977