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P - 35786Building � PLUMBING Perrnit Ivo.:`� t� I Inspections RESIDENTIAL APPLICATION Received By:1� 763-572-3604 CITY OF FRIDLEY ����(�jl�._ 763-502-4977 FAX EFFECTIVE 1-1-20ll � DATE �� Z� I� YOUR E-MAIL ADDRESS V��py C�. ��`�i'��Y�� � I- C O+^� SITE ADDRESS � Z� � �� � � Sst_ � C . THIS APPLICANT IS: ❑ OWNER �CONTRACTOR PROPERTY OWNER/ TENANT CONTRACTOR SUBMIT A COPY OF YOUR STATE LICENSE, BOND AND CERTIFICATE OF INSURANCE PERMIT TYPE TYPE OF WORK: DETAILED DESCRIP7 ...._ .4 � (� _ _ ADDRESS: CITY STATE ZIP PHONE: NAME: V\/` � I�i � LJv�^�t �/' -�-�'� STATE LICENSE # �� � � � 5� �w\ STATE BOND # 2 6� Cl � ADDRESS: ` b��� 1 v �G f f v�'�c� pJ� . CITY_ PHONE 1 S�- C� fj S- ZO �J ) FAX [�4`INGLE FAMILY ❑ NEW [ON OF� WORK � v�.+C� S�'�D U�.c.v� ❑ TWO FAMILY �-REPLACEMENT C\.. c %� ��c.,� ❑ TOWNHOUSE � EXP DATE L Z 3 I 2 C� � Z EXP DATE � Z � I �D� � P� � r��C STATE�ZIP s�'34 6 . 1� FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDtCATE TOTAL NUMBER OF EACH BELOW). MIATIMUM FEE $35.50. � BATH SINK/LAV FLOOR DRAINS ,1 SHOWER WATER PIPING BATHNB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTTiER ($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 AROCESSED 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 'ty of Fridley and with the Minnesota Construction Codes; that I understand this is not a permit but only an application fo a e't work is not to start without a permit on site; that the work will be in ccordance with the approved plan in the of l r ' requires review and approv I �orf� plan . SIGNATURE OF APPLICANT C� i! PRINT NAME ��(�'I�SC � �a�/Ce. DATE � Zg �I APPROVALINSPECTORSSI NATURE DATE City of Fridley Building Inspections Department 6431 University Avenue NE, Fridley, MN 55432 763-572-3604 FAX: 763-502-4977