P - 44907Building
Inspections
763-572-3604 '
763-502-4977 FAX
DATE fyr:I��(��I
SITE ADDRESS �
THIS APPLICANT IS
ROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING perm►t No.: ''
RESIDENTIAL APPLICATION Received By�G�/ _
CITY OF FRIDLEY D����I�I� 2 1
EFFECTIVE 1-I-2011
YOURE-MAILADDRESS 't��✓yNe�50u � �a� ('�.�Lt(0.5�. rt�l
�Z�✓ J c � c�- -T
❑ OWNER �ONTRACTOR
ADDRESS:
� i �c� v✓� CITY
PHONE:�6 3- S%/ - S G�j J
TATE ��"3,iP > S Y3l�
NAME:_ T✓✓7 /��ISa�t ��(JG"�l�/K-y .LuC._ -
STATE LICENSE # S°JOQ Tj � lM EXP DATE /2 - 3/— I�
STATE BOND # � 3 �'I g 3$� I EXP DATE /�- 3/- ��
ADDRESS: I7(��3 ryE',•t �T` CITY � r-✓ STATE I�GV ZIP � S 30 `�
PHONE 6/2-7',l7' ��} 9'7 FAX %`3 �a l��S�"/
�SINGLE FAMILY
❑ NEW
❑ TWO FAMILY ❑ TOWNHOUSE
�.REPLACEMENT
DETAILED DESCRIPTION OF WORK �''�-�0 �0.C,� ,,,,� .�i�'cv k���'f '� ✓
FEES ARE BASED ON $10.00 PER FIX1'URE, EXCEPT WHERE NOTED.
$35.50.
BATH SINK/LAV FLOOR DRAINS
BATHNB GA5 PIPING (NEED CITY LIC;
CLOTHES WASHER KITCHEN SINK
_ DISHWASHER _ LAUNDRY TRAY
FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MIN[MUM FEE
SHOWER
SWIMMING POOL
WATER CLOSET
�WATER HEATER ($35)
_ WAT6R METER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
WATER PIPING
WATER SOF7'NER ($35)
BACKFLOW PREV. ($15)
FOR IRRIGATION
OT'HER
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 wiil be in accordance
with the approved plan in the��I,Lj �vhich requires review and approval of plans. � J
SIGNATURE OF APPLICANT /� iC��- PRINT NAME_ � e�✓7 r'V� I�dv� DATE 3- �Z l- I I
APPROVAL INSPECTORS SIGNAT E 1lATF
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977