P - 45789Buildir�g PLUMBING Permit No.:Za���I��'
Inspections RESIDENTIAL APPLICATION 1Ze�eived By:
763-572-3604 CITY OF FRIDLEY ��
763-502-4977 FAX EFFECTIVE ]-1-2011
DATE � �
SITE ADDRESS _�
THIS APPLICANT 1S:
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
�rrsu�urrcE
PERMIT TYPE
TYPE OF W ORK:
YOUR E-MAIL ADDRESS __�q_
_� �v�-�-�- � e ���. c.sz-
�WNER ❑CONTRACTOR
l.!'��-
5: U �'.t CITY
/„ 17 — '7i=�. —C� � r7 ��
STATE LICENSE #
STATE BOND # _
ADDRESS:
PHONE
❑ SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
❑ REPLACEMENT
CITY
FAX
❑ i'OWNHOUSE
vK ��,��r���.` � � �
STAT�ZIF�,S
EXP DATE
EXP DATE
STATE ZIP
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FI3CTUItES: (INDICATE TOTAL NUMBER OF EACH BELOW). �vIINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB � GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTTIER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($IS)
_ DISHWASHER _ LAUNDRY TRAY =WATER HEATER ($35) �FOR IRRIGATION
WATER METER bTHER
`� � THIS IS AN APPLICATION FOR A PERMIT-NOT VAL[D 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 codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applica ' fo a permit d work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the se k requires review and appro .al of1�lans. ,D
SIGNATURE OF APPLICANT C� PRINT NAME�Gi �I PS �. ��; K-v'�. DATE [�( �2 � r�1
APPROVAL INSPECTORS SIGNA URE DATE—T
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977