P - 44904Building
Inspections
763-572-3604 '
763-502-4977 FAX
DATF. Z �Z� � l �
SITE ADDRESS _�
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
PHONE:
CONTRACTOR N,�E: : r� '
SUBMIT A COPY OF
YOUR STATE STATE LICENSE #
LICENSE, BOND AND STATE BOND # �,��T��!
CERTIFICATE OF ,qDDRESS: ��7 I ��,�( L✓1 CITY
INSURANCE PHONE �3 -�3- 45��
FAX
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE I-1-2011
YOUB E-MAIL ADDRESS �er���%' ✓� � (
❑ OWNER �CONTRACTOR
PERMIT TYPE I WLSINGLE FAMILY
TYPE OF WORK: I O r�w
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
Jq REPLACEMENT
Permit No.: � � �� o�C
Received By: I�_
D��'�'� �= � c .
- -J' - • i -
�STATE ZIP_
EXPDATE I2 �3�-���
EXP DATE I Z r?✓�'- u%l I
%`�_ STATE M/�l ZIP
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV�. MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PII'ING
BATHTUB GAS PIPING (NEED CITY LIC) SWIlvII�4ING POOL WATER SOFTNER ($35)
CLOTf�S WASHER KTfCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY _WATER HEATER ($35) FOR IItRIGATION
WATER METER � OTf�R
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing pernut and I acknowledge that the information above is compiete and accurate; that the work will be in
conformance with the ordinances an odes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applic ' a pe d w is not to start without a permit on site; that the work will be in accordance
with the approved plan in the ca e of rk w i • u' s review and appro s 1 ns /�'- I�<n�,
SIGNATURE OF APPLICANT NAME C����r ��i %% CL�" l DATE �"o�' I
APPROVALINSPECTORSSIGNATURE ,. , /1 DATE��
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977