P - 60355Building PLUMBING I Permit N
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY vate Rec'd: �
763-502-4977 FAX EFFECTIVE 7-1-2010
DATE YOUR E-MAIL ADDRESS
S�� ADD�SS 3 r a �G ,� r�x, St
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
II�1 iii �L�] �[��iL��.��
NAME:�
ADDRESS:
PHONE: `�]l0 3- � �Cq e � ( (�) !
ATF�ZIP .�SU 3
STATE LICENSE # a- EXP DATE `r _�.�p��..
STATE BOND # (3� � if1• EXP DATE
ADDRESS: "JL�"a- � I�J�,�� n S�- CITY %�y1 a IC.� STATE�_ZIP���
PHONE � �3 ��I a �� �g � FAX �(p3 - S� a, " p D �C `7
�SINGLE FAMILY
❑ NEW
❑ TWO FAMILY ❑ TOWNHOUSE
f�PLACEMENT
DETAILED DESCRIPTION OF WORK l��QhL---���
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (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)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTf�R
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL 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 code of the City idley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a pe it and o is not to start without a permit on site; that the work will be in accordance
with the approved plan in the c e of all w w'c re ires review and app oval of pl�1s. , /�7 �
SIGNANRE OF APPLICANT ' - R�AME �Lt Y9� f'J �"ZS�+Y) +� on 5 DATE �'" !�" �
APPROVAL INSPECTORS SIG ATURE
City of Fridley
— Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977