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P - 35772Building PLUMBING Inspections RESIDENTIAL APPLICATION 763-572-3604 CITY OF FRIDLEY 763-502-4977 FAX EFFEC�nvE �-�-zo>> �A� � 1 ��11 SITE ADDRESS � THIS APPLICANT IS: PROPERTY OWNER/ TENANT CONTRACTOR SUBMIT A COPY OF YOUR STATE LICENSE, BOND AND CERTTFICATE OF INSURANCE PERMIT TYPE YOUR E-MAIL ADDRESS 5 c.... r: t..� �.r . '� , � • ❑ OWNER �CONTRACTOR ADDRESS: CITY PHONE: NAME:_in/`-l.. .1�!`u�/�.^���.r �'e.�_� STATE LICENSE # STATE BOND # ADDRESS: ���C� �4,I�1 ��i�n� � � CITY L.c�e.' PHONE R S 2—�� S�- Z � 3 � FAX � SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE TYPE OF WORK: I� NEW �REPLACEMENT DETAILED DESCRIPTION OF WORK _�� , .� iv�. Ta.�..1� c�...e� �s �•:, s.n �- r..� Permit No.: Received By:�!�� i EXP DATE �1EX_P DATE �v�. i f ��t ATE ZIP. 'ATE�ZIP S3 6 ��o�.• ve� .� FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXNRES: (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) 1 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 acknowl ge that the information above is complete and accurate; that the work will be in conformance with the ordinances and codes of th ty of Fridley and with the Minnesota Construction Codes; that I understand this is not a permit but only an application for a p ' nd work is not to start without a permit on site; that the work will be in ac ordance with the approved plan in the c s o 1l r 'ch requires review and approv,�� f p ns. c/ SIGNATURE OF APPLICANT PRINT NAME �/ �'G� �- L ��(� DATE cl / t APPROVALINSPECTORSSIG ATURE _ DATE City of Fridley Building Inspections Department 6431 University Avenue NE, Fridley, MN 55432 763-572-3604 FAX: 763-502-4977 u� s�v