P - 39614Building PLUMBING Perrnit Ivo.: � �
Inspections RESIDENTIAL APPLICATION Received B:
763-572-3604 CITY OF FRIDLEY ����� �� ,. � L
763-502-4977 FAX EFFECTNE 1-1-2011
DATE �'�'r --Y�O'UR E-MAIL ADDRESS I�1�L G� 6�u � �li�'�i�C,%�l��l IA,YY! Io(h�_(i�"
SITEADDRESS I� V Iu.C,�' r� (�. /C!.j"/'/aC':Qr
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY NAME: i ' .�-�
OWNER/ ADDRESS: 1� � � CI K1L �� � 1 Utx. CITY STATFM ZI
TENANT pHONE: �y+3 " � o� -' O`�I �% �
CONTRACTOR NAME:�r%�,/ (�i�.Y"(�L�r I��GCmb+rtR /
SUBMIT A COPY OF STATE LICENSE # (1 � � / � � ��% J EXP DATE / � � � I - � �
YOUR STATE q �
LICENSE, BOND AND STATE BOND # Cin l t.-¢� EXP DATE
CERTIFICATE OF ADDRESS: ^O a. , CITY_ /10 KG� STATE ZIP-����.'�. ,
INSURANCE pHONE `� (e 3— 5 I/� "� (g O FAX��n3 -�%2l -�5 B S�J
PERMIT TYPE �SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW �J REPLACEMENT
DETAILED DESCRIPTION OF WORK �, n5 �- W� �t
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
BATHNB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($IS)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
�L��F 0��1�!E�E11�S � ���i.{� lG�1��Q = �t ' � �
,
�1'��Tt?��llCt131`�S 4�,�1��{i{} IC�1$.{1Q $ - , �
�iut�tr�,�u�s {c� $35.(�D � x $3Satl4 = � �� • ��
�;:
�tat:e �r�J�ar�e ; �
4 ti Tatat = $ _��
UM$O.Q.
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 work will be in
conformance with the ordinances and des of th City of Fridley and with the Minnesota Construction Codes; that I understan this is
not a permit but only an application f r erm' and work is not to start without a permit on site; that the work will be in a ord ce
with the approved plan in the +equires review and ap�r.�'al of,}� lans. (�,
SIGNATURE OF APPLICA — PRINT NAME IC'r'ru lJlJ�Q.I"GiG�i' �F DATE 'r' �
APPROVAL INSPECT SI RE ,:. DATE
PT.,EASrE NUTE: E�RA'TE F+� �.IIR� F�%� $[:1�,I}�P3G �`T.E+�"�T�'AI.F A�'Q �r�C �
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
��