P - 45120Building PLUMBING P��zt No.: i
Inspections RESIDENTIAL APPLICATION Received Bf�
�63-s�2-3604 �IT� OF FRIDLEY �f�k�d�j�►
763-502-4977 FAX EFxECTTVE i-t-ZOi�
DATE .�a r„� . G ZC 1� YOUR E—MAIL ADDRESS
sirE A�n�ss �_� fo 'S l�. �1�,i�- ����� ��,. �t c��S
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY N�:
OWNER/ pDDRESS: CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR xp�: �,�,,, 1 .
SUBMIT A COPY OF '�C� � 5� EXP DATE NQII • 2,[L�
YOUR STATE STATE LICENSE #
LICENSE, BortD r� STATE BOND # �� I rJ S�� �P p�TE �� �1. 2�! I —
CERTTFICATE OF �DR6SS: O J' -' �✓t � �. �i _�• CITY S-� . C�� � STATE_�ZIP����,
INSURANCE pHONE � SZ� Z"j Z" � S S b FAX
��SZ 2� S- �g�2
PERMIT TYP� � SINGLE FAMILY ❑ TWO FAMILY �TOWNHOtJSE
TYPE OF WORK: � NEW �REPLACEMENT
DETATLED DESCRIPTION OF WORK ���nl �,�C'n w1�,v� � C� W�'�__ ei� �j2G T�2.v�'
FEES ARE BASED ON $10.00 PER FIX1'URE, EXCEPT W�IERE NOTED. FIX1�lRES: (INDICATE TOTAL NUMBER OF EACH $ELOV1�. M[NIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER �IPING
� BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL T WATER SOFTNER ($35)
� CLOTHES WASHER i KITCHEN SINK WATER CLOSET � BACKFLOW PREV. ($IS}
DISHWASHER � LAUNDRY 7'RAY �WATER IIEATER ($35) FOR IRRIGATION
WATER METER OTHER
Nurnber of fixtures @$10.00 x 510.00 =$
Number of fi�rtures @$ I 5.00 x$15.W �$
Number of fiactures @ $35A0 � x $35.Q0 = $ 3 ' �
State Surcharge $ 5.00
INIMiTM $40.00 Tota1= $
THIS IS AN APPLICATION FOR A P�RMIT—NOT VALID [INTIL 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 an de of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an appl' tion or rmit and work is not to s without a permit on site; that the work will be in accordance
with the approved plan in ase f 1 re 'res review approv 1 of plan .
SIGNATURE OF APPLIC A ¢. ' t°" C. DATE ".i0 "� I
APPROVAL INSPECTO RE DATE
PLEASE NOTE: SEPARATE PE 1NG, ELEGTRICAL AND ME C
f'itv nf Frir�lev
Building Inspections Department
6431 Universitx Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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