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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