P - 44973Building PLUMBING � Permit No.:
Inspections RESIDENTIAL APPLICATION xeceivea ByV� �
763-572-3604 CITY OF FRIDLEY �►'.���N ��� Z�) '
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE�� �//�/ YOUR E-MAIL ADDRESS
S[TE ADDRESS ,�l�S• ,iT'i r?/, ("pri� I� %v"�.
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTTFICATE OF
INSURANCE
❑ OWNER �CONTRACTOR
NAME: Gf1 9-'^'lGNi� i �I� �1/,�'G �✓
ADDRESS:��aw✓" CITY_
PHONE:
NAME: S'�p`a1�sC�f' �"�f�liAq�' _��-•
STATE LICENSE f� O�'S� EXP DATE
TE ZIP
STATE BOND # EXP DATE �
ADDRESS:�%c7( %/�[.�� e.�./�- CITY�-i�t/'o/�i[..� STATE ��f/ ZIP�
PHONE �Ltj �1 C�'' /a-G % FAX 7C�'"d(�oL"'���
PERMIT TYPE I I�INGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: I � �EW �PLACEMEtVT
DETAILED DESCRIPTION OF WORK �lG�:� ,Qa,,,�
FEES ARE BAS6D ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
_ BATHNB GAS PIPING (NEED CITY L1C) _ SWIMMING POOL � WATER SOFTNER ($35)
_ CLOTHES WASHER �IKITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) ^ FOR IRR]GATION
_ WATER METER OTHER
THIS [S 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 will be in
conformance with the ordinances and codes of the Ciry of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an appiication 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 k� -'c requires review and approv an,.s/ 1.,
SIGNATURE OF APPLICANT � �<yti�pRINT NAME /S�- %`�r i�-i[tr,wy� / DATE �
APPROVALINSPECTORSSIGNATURE naTF
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
'763-572-3604
FAX: 763-502-497'7