P - 39639Building PLUMBING Permit No.�� l�-- c�� 3
Inspections ��IDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date xec'ct:
763-502-4977 FAX EFFECTivE �-�-zo>>
DATE � ! H "I� 61
SITE ADDRESS __,
THIS APPLICANT IS
PROPERTY
OWrTER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
1��:7u I fl���
TYPE OF WORK:
YOUR E-MAIL ADDRESS
� ��
❑ OWNER CONTRACTOR
NAME: �
ADDRESS: �Ip�GL KI�II,S YI� ���
PHONE: �t (Q � .. � � �F .- ( � b�'
NAME: /�1 V�{� t,R✓ Y�(,�//I %L�/
STATE LICENSE #
STATE BOND #
ADD�ss: � 1� LL�1 � 1 � ? �7
PHONE � �'` I � '`"! �i
l,� S�NGLE FAMILY
r ��
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
�REPLACEMENT
_CITY F't�/ 0►�/'�/�/
EXP DATE _
EXP DATE _
CITY
_ FAX
❑ TOWNHOUSE
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV _FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATERCLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ 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 wark 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 an wor s not to start without a permit on site; that the work will be in accordance
with the approved plan in th� e o all w which e s review and approv 1 of - lans,f;. c�
SIGNATURE OF APPLICANT P T NAME �/� L�`r�� DATE 0 ��
APPROVAL INSPECTORS SIGNA / � ' DATE L/
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977