P - 44959Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �c-;- �y- ��
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
1NSURANCE
PERMIT TYPE
PLUMBING
Permit No.
RESIDENTIAL APPLICATION Received By: ���.
CITY OF FRIDLEY ����:C�f ,��
EFFECTIVE 7-1-2010
YOUR E-MAIL ADDRESS �t�lnvl �.SD�--tiJ �i@ J� }7I U.�-t �r.t'e% P C G9 ���
�Q � 'R
O OWNER
ADDRE35:
STATE LICENSE # S �3 S
CITY STATE ZIP
EXP DATE /d ` -f�'
STATE BOND � EXP DATE
ADDRESS: �D� �O�C � O F� CITY � P /� STATE�ZIP SSO/
PHOWE '7�U.3 � '�f�{�{ Oc?%Z FAX %�� ' '���- 7.3J� �%
�SINGLB FAMILY O TWO FAMILY ❑ TOWNHQUSE
TYPE OF WORK: � NEW �REPLACEMENT
DETAILED DESCRIPTION OF WORK C� �P� �,y t'
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEFT WHERE NOTED. FIXTURES: (MDICATE TOTAL NUMBER OF EACH BELOW). MiNIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPIIVG (NEED CITY LIC) � SWIMMTNG POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SMK WATER CLOSET BACKFLOW PREV. ($15}
_ DISHWASHEIt` _ 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 I acknowledge that the information above is complete and accurate; that the work wi[I be in
conformance with the ordinance and codes of the C' of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an appli tio for pe work is not to start without a permit on site; that the work wilt be in accordance
with the approved plan in the e f a o whi requires review and approval of pl ns.
SIGNATURE OF APPLICANT < PRINT NAME �ol�v� ��. S�c�A.'�/�- DATE I� -�y� ��
APPROVAL INSPECTORS SIGN .fiUR
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977