P - 47299Building
Inspections
763-572-3604
763-502-49.77 F
DATE�SITE ADDRES
THfS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE i-I-201I
�
��U
❑ OWNER
NAME: � �
� � � - aa���--
Permit No.:
Received By:
Date Rec'd:
YOURE-MAILADDRESS �"'�°� iCQ-� C�yhcaS�`qe�--
L�l� �!'I`u��
❑CONTRACTOR
m r1 /� Gr r/) C'J
ADDRESS: �/?f�- /Y�- L/�P� �C/�f
PHONE: �— �/�2� �D� ��L��
NAME: I Lt I'S ri.n �i, i�n
AT&�/�ZIP SS
STATE LICENSE # S g l I l J EXP DATE �� � 3�!- I o�
STATE BOND # EXP DATE
ADDRESS: ��-Sc�-Y I S°� . CtTY rlq�o% (T,^OViC STATF/y1N ZIP _SS3�9
PHONE `� �_L�93 - �(%'� Q FAX
TYPE OF WORK: �� NEW
FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
DETAILED DESCR[PTION OF WORK
�EPLACEMENT
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINfMUM FEE
$35.50.
_ BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
_ BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
_CLOTHES WASHER KITCHEN S1NK WATER CLOSET BACKFLOW PREV. ($IS)
_ DISHWASHER _ LAUNDRY TRAY _WATER HEATER ($35) FOR IRRIGATION
_ WATER METER �OTHER ut �u-e_
�i�a iw
TH[S 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 comptete 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 1 understand this is
not a permit but only an application for a permit an work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case of all which r quires review and approval of plaJ�s.
SIGNATURE OF APPLICANT PRINT NAME %� � t/c /�.L I. S uo✓'�S/�, ' DATE ��.23 �1
APPROVAL INSPECTORS crc ATII � � _
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977