P - 482588
f
Building
Insgections
763-572-3604
763-502-4977 FAX
DA1� /G�11 L
SITE ADDRFSS _
THIS APPLICANT IS:
PROPERTY
owrrE�
TENANT
CONTRACTOR
SUBMTT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
�rYrE oF wo�:
PLUMBING Permit No � Y?�) �
RESIDENTIAL APPLICATION R�el�ea By: , ,
CITY OF FRIDLEY ���N �'�' �`
EFFECTIVE 1-I-2012
YOUR E-MAIL ADDRESS S r�� c,�l • � C6YY� Ce-J'�, �l-�
n SDn I.Jci N� 1
❑ OWNIER �CONTRACTOR
��ss: `� � I� st7 n o n
PHONE: � ip3 � '�I n � � � SS
_�-1-.�
NAME:�� �
S'I'ATE LICENSE # P L S C
STATE BOND # U1 15D 1 Oq 6`7 �
0
EJ� DATE
E7� DATE
z�r,S �f32
,�n�ss:__ �,�3 Cn�..+rr� l��-e- c�� 0 Sse c� sTA� Mr� z� 55 3 b9
PxorrE _7Io,3 - 57 I- o �f s�F F� 71p3 -�{ as - 7�{� I
�SINGLE FAMILY
❑�w
DETAILED DESCRII'TION OF WORK
❑ TWO FAMII.Y Cl TOWNHOUSE
.��r�acEMErtT
FEES ARE BASED ON S I0.00 PER FIXTURE, EXCEPT Wf�RE NOTID. FIXT[JRES: (II�iI?ICATE TOTAL NUMBER OF EACH BELOR�. MINIMUM FEE
535.50.
BATH SINK/i.AV FI,OOR DRAWS SHOWER WATER PIPING
BATHTUB GAS PII'ING (NEED CTTY LIC� SWII�A�IING POOL WATER S(3FTNER (S35)
CLOTHES WASHER KTI'CHEN SINK WATER CL�EI' BACKFLOW PREV. (�15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER (S35) FOR IRRIGATION
_ WATER METER _ OT[�Qt
Number of fixtures @ $10.00
Number of � @ a15.00
x$10.00=$
x $15.OQ = $
Number of Sxhares @ 535.00 � x�35.00 =� ;�.1 ��
State Sur�harge
$ 5.0(1
= s �Pb � o_°
THIS IS AN APPLICATION FOR A PERMIT�+TOT VALID UNTIL PROGESSED
I hereby apply for a plumbing }�eimit and I acknowledge that the information above is comptete and acxurate; that the worlc will be in
conformance with the ordinances and codes f the ' of Fridley and with ffie Minnes�a Constructi� Codes; ii�at I understand this is
not a permit but only an application for a 't an w rk is not to start without a permit on site; that the work w�11 be in accordance
with �e approved plan in theS of a11,�}'�k w' review a�id ap va1 of lans.I'�, r
SIGNATURE OF APPLICANT r���,�,�,� ¢�{2C.�-� . PRINT NAME� Y�d�. Tt�.l �'1 DATE �/Z31 I Z-.
PLEASE NOTE: SEPARATE
FOR BUILDING, ELECTRICAL AND
�(:ity of Fridtey
g Inspections Department
iversity Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977