P - 44932Building
Inspections
763-572-3604
763-502-4977 FAX
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTTVE 1-1-201 I
Permit No.: r� �� �'�-`�%
Received By: ?����
���� AY 2 0 201
DATE ,�'Z6- � �� YOUR E-MAIL ADDRESS ����
SITEADDRESS S�� R��-C-' C��IC �ft1� %%� ,} �li����/
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIF[CATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
c :�
ADDRESS: `51�0 K��� L:-�CeK lStU� "{G C�TY
PHONE:
S'TATE LICENSE #
EXP DATE
ATE flll "ZIP ���3 �
STATE BOND # EXP DATE
ADDRESS: LI�.3 �Ct �S4i� �'VC? SC.� CtTY ZSQ/�, ' STATE� ZIPSS��
PHONE `Z63� ZQ! I 'S�Z.SrZ. FAX
�
3iNGLE FAMILY
�NEW
� TWO FAMILY 0 TOWNHOUSE
❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK �S'�.1� U�AC�-t,c� �iteo.�cC') ���pr; tik p_,y� s�.
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACN BELAW). MiNIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER
BATHNB T GAS PIPiNG (NEED CITY LIC) SWIMMING POOL
CLATHES WASHER KITCHEN SINK WATER CLOSET
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35)
WATER METER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
WATER PIPING
WATER SOFTNER (S35)
� BACKFLOW PREV. ($15)
FOR IRRIGATION
_ OTHER
I hereby apply for a plumbing pennit and I acknowled e that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of t ity of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application fo i d ork is not to start without a permit on site; that the o will be in accordance
with the approved plan in the cas al requires review and approva ofL;l,an�s. y�a� � ��Q`'�''^
SIGNATURE OF APPLICANT INT NAME �� 11J �� � l DATE
APPROVALINSPECTORSSIGNATURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977