P - 44930Building
Inspections
763-572-3604
763-502-4977 FAX
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-1-2011
Permit No.�O
Received By�
�� ���
DaTE �- 28- I I Youx E-M.aiL ADD�ss LPAL�TE �i G�"rA= L• GOM
s�TEaDD�ss 4953 ab►"64N TzD FP-7D�Er MN �5�121
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
�OWNER ❑CONTRACTOR
ADDRESS: �"�q53 �DMA/� Rp CITY ����i STATE/�/�ZIP���.�
rxotvE: Po�31-33$-3olg
STATE LICENSE
STATE BOND # _
ADDRESS:
PHONE
� SINGLE FAMILY
❑ NEW
❑ TWO FAMILY
�REPLACEMENT
FAX
❑ TOWNHOUSE
EXP DATE
EXP DATE
TATE ZIP
DETAILED DESCRIPTION OF WORK �� R��") R�l`'1�D-
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
�. BATH SINK/LAV FLOOR DRAINS I SHOWER WATER PIPING
BATHTUB GAS PIPING (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
I hereby apply for a plumbing
conformance with the ordinan�
not a permit but only an appli
with the approved plan in the c
SIGNATURE OF APPLICANT
APPROVALINSPECTORSSIGNA
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I acknowledge that the information above is complete and accurate; that the work will be in
;s of the ity of Fridley and with the Minnesota Construction Codes; that I understand this is
k�ermit d work is not to start without a permit on site; that the work will be in accardance
y�l� w' h�equires review and approval of plans. �!
1��1 . PRiNTNAMR LCGAN Af]AN1G-L���i"� DATF. �"Zv���
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977