P - 44971Building PLUMBING Permit No.: tl�2�I��'
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date Rec' :
763-502-4977 FAX EFFECTTVE i-i-aoii " �
DATE YOUR E-MAIL ADDRESS
si� aDDt�ss !v 3 !o / ,7'1.�. �'�'�Go�L�2e� .. �'Ylin. 5a<</� Z
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY N,�:
�w�� ADDRESS: CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR N,�: /�a r L�y N• 1,Vea.ve,r' .T.Ne .
SUBMIT A COPY OF STATE LICENSE # 058' D y 4—"' � M EXP DATE I Z.' 3 I� ZO�Z
YOUR STATE
LICENSE, Borm �tvv sTn� Borm u/� L!a� S� o0 8 EXP DATE I y- 3 t- �.a ! 1
CERTIFICATE OF �DRESS: CITY STATE ZIP
INSURANCE
PHONE FAX
PERNIIT TYPE VhT�GLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: O NEW [�REPLACEMENI'
DETAILED DESCRIPTION OF WORK
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELO�. MINAdUM FEE
$35.50.
BATH SINK/LAV _FLOOR DRAINS SHOWER WATER PIPING
� BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER (S35)
CLOTHES WASHER KITCHEN SINK � WATER CLOSET BACKFLOW PREV. (S15)
DISHWASHER _ LAUNDRY TRAY �WATER HEATER (S35) FOR IRRIGATION
WATEIL METER OTf�R
� , : ., << = . � �' � �; �� '� �; � �
hTtumber crf%ctur�ss @ $1Q.tiCi x �1fl.0U = � •_>
Aiumber of fixtures @ $15.00 x $I5.00 = $ ,
Number of fixtures @$35.00 x$35.00 =� l
State Surcharge $ 5.00
$40.00 Tota1= � �� . O
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID iJN'I'II. PROCESSED
I hereby apply for a plumbing pe ' and I acknowl e that the information above is complete and accurate; that the work will be in
conformance with the ordinan d codes of the of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an a ' a' n for a pe ' d work is not to start without a permit on site; that the work will be in accordance
with the approved plan ' th e o 1 ' h requires review and approv 1 o�plans. �/
SIGNATLTRE OF APPLIC PRINT NAME�.Q P v /I/ G�Q /F� reQ DATE /" a�' a U I/
APPROVAL INSPECTO SI NA � DATE
PLEASE NOTE: SEPARA PERMITS ARE RE UIKED FOR BUILDING, ELECTRiCAL AND MECHA�TICAL W�RK
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977