P - 84382Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY t�F FRIDLEY
763-502-4977 FAX EFFECTIVE I-1-2012
DATE I �"' � 7`
SITE ADDRESS S'
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
� Z- YOUR E-MAIL ADDRESS _
�( W �2hnef ORSf F� ic��e� ..U.A/ S�Sy
OWNER OCONTRACTOR
NAME: �� S • � W &� � ^ �-,i
ADDRESS: � LI z I In► � C"�n e't� � S s
PHONE: �63—Z�IL-79`�'Z.
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
STATE LICENSE #_
STATE BOND # _
ADDRESS:
PHONE
1]�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
;dc�lb�lt�a
L
Permit No.� �
r-
Received By�v
Date Rec'_d;
r�et; 1��'0....-�
C1TY Fi �c ��� l( STATE+�� ZIP ��1Z
EXP DATE
EXP DATE
_CITY STATE ZIP
FAX
❑ TWO FAMiLY �TOWNHOUSE
❑ REPLACEMENT
A Ive �
FEES ARE BASED ON $] 0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW).
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPMG
BATHTUB GAS PIPiNG (NEED CITY L1C) SWIMMING POOL WATER SOFTNER ($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 PROCESSED
I hereby apply for a plumbing permit and 1 acknowledge that the information above is comp)ete and accurate; that the work will be in
conformance with the ordinances and codes of the Ciry of Fridley and with the Minnesota Construction Codes; that 1 understand this is
not a permit but only an applica 'on for a permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in ca of al work w h requires review and approval of plans � � �,� � 9_� z.
SIGNATURE OF APPLICANT -��'�-� C � PRINT NAME �� S o n ��� I r^�� DATE
APPROVAL INSPECTORS S ATURE _ � DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977