P - 44918Building PLUMBING Permit No.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date��t}: N1�1Y �"?' 1
763-502-4977 FAX �FECTrvE i-i-aoi i
DATE �II � � � YOUR &MAIL ADDRESS
SITE ADDRESS `� I'7 � 1 ��L� 1� I �(,� '�-e.v'Y'c� c.p
THIS APPLICANT IS: ❑ OWNER �(;ONTRACTOR
PROPERTY N�: � '
�WNER/ ADDRESS: 2�(,�? .CITY i'f'i G�� p.ul STAiti�1 ZIP��2
�x`� PHONE: '1 3- 5 7� - I S$ 1
CONTRACTOR �qME: � � � � ,�
SUBMIT A COPY OF
YOLJR STATE STATE I.ICII�TSE # EXP DATE � 2 �! � 1 Z
LICENSE, BOND AND STATE BOND # Ie � � EXP DATE ��/�/ ZD /'Z-
CERTIFICATE OF ADDRESS: CITY SSQ,O STATE ') � ZIP '�r' S ID
n�rsu�xcE PHOAIE 7ti 3- 5�!- D�{ S�{ FAx -7�0 �- yf���u !o I
PERMIT TYPE �SINGLE FAMiLY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � �' ������
DETAII..ED DESCRIP'TION OF WORK K.Q.�p�tLG¢, � D OXU•.� L Q I'L. NCc�c�'!u� C��S �I.11 �IPi✓ �P��.
_�
FF�S ARE BASED ON St0.00 PER FIXT[JRE, EJCCEPT WHE[tE NOTm_ FiXTURES: (IlVDiCATE TOTAL NUMBER OF EACH BII.O�. MQdIMCIM FEE
$35.50.
BATH 3INK/LAV FIAOR DRAiNS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CTI'Y LIC) SWiMMING POOL WATER SOFINER (�35)
CLOTEIF.S WASHER KTI'CHEN SINK WATER CLO�SET �BACKFLOW PREV. (Sl�
DISHWASHER _ LAUNDRY TRAY �WATER HEATER (S35) � FOR IRRIGATION
— wA� MEr� o�
Number of �tures (a� $20.OU x 514.00 = $
Number of $xtures @ $I5.0(? x �15.00 = $
Number of fiadures @$35.00 1 x 535.04 =$��• Q 0
State Siucharge $ 5.00
S4o.o0 Totai =$ LiD o 0 O
THTS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing pernut and I aclmowledge 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 Const�vction Codes; that I undeastand this is
not a permit but oniy an application for a permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case of all rk wtrich requires review and approval of plans.
SIGNATURE OF APPLICANT PRIN'I' NAME DATE �
APPROVAL INSPECI'ORS SIGNATURE DATE
PLEASE NOTE: S�I'�1RATE RE FOR DIl�TC ELEC'IRIeAr, AND C ORK
City of Fridley
Building Inspections Dep�rtment
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: ?63-502-4977
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