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P - 44988Building PLUMBING Inspections RESIDENTIAL APPLICATION 763-572-3604 CITY OF FRIDLEY 763-502-4977 FAX EFFECTIVE 7-1-2010 DATE '� �� SITE ADDRESS � THIS APPLICANT IS: PROPERTY OWNER/ TENANT CONTRACTOR SUBMIT A COPY OF YOURSTATE LICENSE, BOND AND CERTIFiCATE OF IIt1St1RANCE PERMIT TYPE TYPE OF WORK: YOUR E-MAIL � 1 r^- . ❑ OWNER '�CONTRACTOR NAME: � �WI/C �✓�, ADDRESS:6�SG JTl Y�,SD`^. I��Y • CITY PHONE: 7(s .3 � S%/� 9/�{ 3 Permit No.: l�i� � Received By!! �" Da�e'F,�d� � � A' NAME: � 0.►/�,l�- S�YU S d 1 � STATE LICE SE #���JSS ( V�� EXP DATE STATE BOND # EXP DATE ADDRESS: IO . L r �• N CITY_ �i1 �►� �AJ�-Q� STATE/y /�%_ZIP���� PHONE JJr' 2- yb 9" � 3 � FAX 952- �169'��� I� SINGLE FAMILY /' ❑ NEW DETAILED DESCRIPTION OF WORK ❑ TWO FAMILY ❑ TOWNHOUSE �REPLACEMENT 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 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 THIS IS 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 City of Fridley and with the Minnesota Construction Codes; that I understand this is not a permii but only an ap ication for a aermit and work is not to start without a permit on site; that the work will be in accordance with the approved plan in t ase of� � ich requires review and approval of pl s. SIGNATURE OF APPLICANT * A T* Tn PRINT NAME�j/�'� �(,�,��, � _DATE I' "'`��� D City of Fridley Building Inspections Department 6431 University Avenue NE, Fridley, MN 55432 763-572-3604 FAX: 763-502-4977