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