P - 84359i�� 1��
Building PLUMBING Pe�it No.:
Inspections RESIDENTIAL APPLICATION Received By: ��
763-572-3604 CITY OF FRIDLEY vate Rec'd: `�
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE YOUR E-MAIL ADDRESS
SITE ADDRESS
THiS APPLICANT IS: ❑ OWNER DCONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTiFICATE OF
INSURANCE
PERMIT TYPE
NAME: , o� ✓l 'G
ADDRESS: S��S A5 r< c Cr�c �� CITY ��� , STAT �2 ZIP� 2
PHONE: d�}' ��7 S%/ �f%
NAME: �+ . +�
STATE LICENSE # C�/Ci(�O % EXP DATE -�f U�-Z
STATE BOND # {P DA E .2Q ��
ADDRESS: / � �' i� . C'I�� CITY � STATE � ZIP�
PHONE FAX
TYPE OF WORK: I� NEW
FAMILY ❑ TWO FAMILY
�REPLACEMENT
DETAILED DESCRIPTION OF WORK /�� n/a. c, � f'.
❑ TOWNHOUS£
i
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: ([NDICATE TOTAL NUMBER OF EACH BELOW).
�BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPMG
� BATHTUB _ GAS PIPING (NEED CITY LIC) SWIMMING POOL _ WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN S[NK � WATER CLOSET 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 1 acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of e Ciry of Fri ley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit w � not to start without a permit on site; that he work will be in acc rdance
with the approved plan in the cas of all ork quir review and approv f plans.
SIGNATURE OF APPLICANT Pjt,jj�IT N(�ME c v�- DATE �� O��
APPROVAL INSPECTORS SIGNATURE , ,C/iit�/ DATE
" City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977