P - 44925Building
Inspections
763-572-3604
763-502-4977 FAX
DATE 1 ! � I �
SITE ADDRESS �
THIS 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 1-1-2011
. . _ ,
CJ OWNER
_ YOUR E-MAIL ADDRESS
�,Z_�c rr...GG
�ONTRACTOR
NAME: � �.. � : u �.s, v�n S
ADDRESS:��j�_�; .zrt/: � t�fb��� CITY,
PHONE:
Permit No.:
Received By: '` .�-
D�t'�Q���:PR 1; 201
;���,�.�.-� �,�_� �� .
STATE LICENSE #
STATE BOND # "
ADDRESS:�
PHONE C� I �
SINGLE FAMILY
TYPE OF WORK: I o NEW
.
�
� TWO FAMILY
�REPLACEMENT
EXP DATE
EXPDATE
CITY ��
FAX °'^�
❑ TOWTIHOUSE
A
A
DETAILED DESCRIPTION OF WORK K�w,ad-l� c7'S-' SS; i5'°I" ���pi �.�,J � ����'j2 ,/. �L,p ��
-.r'.�� %1 h�.,�'�►. � R� (v��e- ,� 1'�.r.v�
FEES ARE BASED ON $ f 0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (iNDiCATE TOTAL NUMBER OF EACH BELOW), MIN[MUM FEE
$35.50.
� BATH SINK(LAV _FLOOR DRAINS � SHOWER � WATER PIPTNG
,� BATHTUB GAS PIPTNG (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER � KiTCHEN SINK �, WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
` WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NQT VALID UNTIL PROCESSED
I hereby apply for a plumbing pennit 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 application for a permit and ork is t to start without a permit on site; that the work will be in accordance
with the approved plan in the c f all work ich re ire eview and appro al of plans.. —� t
SIGNATURE OF APPLICANT P�N_T 1�4ME �c,`n.�.� `��e,scM�a,.� DATE G—
APPROVAL INSPECTORS SIGIVAT ,_ %l/%// i14TF /i� /
" City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977