P - 48090Building PLUMBING Permit No.: ���; �'�
Inspections RESIDENTIAL APPLICATION Receivea By:
763-572-3604 CITY OF FRIDLEY D��°� AY � Q D'
763-502-4977 FAX EFFECTIVE 1-I-2011
DATE J'�� �� d O� YOUR E-MAIL ADDRESS
SITEADDRESS �D6 �l�C� �Y-G��C /1`G,yrAce
THIS APPLlCANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
❑ OWNER 7$CONTRACTOR
NAME:
ADDRESS: CITY STATE ZiP
PHONE:
NAME: a
STATE LICENSE # O S� J�� I'� EXP DATE /�� 3/-� G I Z
STATE BOND # � S f j� J� J7� EXP DATE _I � 3�, l� at] �I
ADDRESS:__ /6 3-�% � �� rr G CITY __ C c �Ja ✓ STATE !��/Z1 P Sf0 /%
PHONE `��,�5!3 t�` .�S fr � FAX 2�- �/'� �/' ,�SFl S�
�.SINGLE FAMILY
❑ NEW
❑ TWO FAMILY � TOWNHOUSE
�REPLACEMENT
DETAILED DESCRIPTION OF W ORK ,Q�,�/p c Q �i Y�"'(A✓ < � �n 4 S�z i i� rh .�m.� i� .i�bZ TJ� :
13•o.t� tr, � �..T �3•4 r-�
FEES ARE BASED ON $10.00 PER FIXT[1RE, EXCEPT WHERE NOTED. FiXNRES: (INDICATE TOTAL NUMBER OF EACN BELOW). MINIMUM FEE
�$ .50.
BATH SINK/LAV _FLOOR DRAINS L SHOWER
BATHTUB GAS PIPING (NEED CITY L1C) 3WIMMING POOL
CLOTHES WASHER � KITCHEN SINK � WATER CLOSET
,� D15HWASHER _ LAUNDRY TRAY �VWATER HEATER ($35)
_ WATER METER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
WATER PIPING
_ WATER SOFTNER ($35)
BACKFLOW PREV. (S15) ,
FOR IRRIGATION
OTHER
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 th Ci of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a perm'it and ork i ot to start without a permit on site; that the work will be in accordance
with the approved plan in the c Il r' hic eq ir review and approval of lans. /
AP ROVAL NSPECTORS SI ATUR �AME �� S��/�4 aG� DATE ` /" ��I
I�ATF
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977