P - 44995Building p�.,�J�����
Inspections ��5����T���� ��p��������T
763-572-3604 ���,� ��, ������
76J-JQ2-49 / 7 F��i EFFECTNE 1-1-2011
DATE �� C�
SITE ADDRESS _
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
OWT�IER
NAME: I U r 4•
ADDRESS: �
PHONE: � ' �p � rl
YOUR E-MA[L ADDRESS
CITY
Permit No.: a�
Received By:�/
�����R 1
ATE
CONTRACTOR NAME:�U V� �T'I ���� %k9
SUBMIT A COPY OF STATE LICENSE # EXP DATE
YOUR STATE
LICENSE, BOND AND STATE BON # EXP DATE
CERTIFICATE OF ADDRESS: C CITY STAT�IP J� 2
INSURANCE pHONE __ �'_ �'� ZL� ___ FAX aJ'
PERMTT TYPE
TYrE oF wo�: I� NEW
FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
DETAILED DESCRIPTION OF WORK
�PLACEMENT
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATHSINK/LAV _FLOORDRAINS SHOWER WATERPIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATERCLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY 1WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID iJNTIL 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 permit but only an application for a pe it o k is not to start without a permit on site; that the work will be in accordance
with the approved plan in th �� of a� work whic i y ires review and approva �f lans. I'
SIGNATURE OF APPLICANT _t��K//" L� PRINT NAME �i G� GGL�G� DATE `� � (
APPROVAL INSPECTORS SIGNATURE T-DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977