P - 45121Building
Inspections
763-572-3604
763-502-4977 FAX
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFEC"I'IVE 7-1-2010
Permit No..�� �
Received By: � ► �'
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DATE �Q �� V� ! O YOUR E-MAIL ADDRESS l'17 t l�-(,' � 1rV �( SS �y u t��� ^�� �� r,'-� e.�, I u.� be�,. � e
szTEavDn�ss SE6e iN $AVA���4h! P�SS' Fk��tc^y /ZtN SS�-32�(�br��
THIS APPLICANT 1S: ❑ OWNER �dCONTRACTOR
PROPERTY
OWNERi
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSLJRANCE
PERMIT TYPE
TYPE OF WORK:
NAME: ! IoI � K�= L� �.SO 1V
ADDRESS: �� 6 C' �r .��Q i1� R/� AJ Pf� �1-f CITY /Lf2 �� L� y STATE�/�ZIP .,�.5`{32 -
PHONE: C�TG 3� 2�I- 2- 3 b 7� E CC' �
NAME: �jdvR FAvcF��;� �CJM$�,2, LLC MICF�/�CL R j�LJJ'S
STATE LICENSE # C:1 �D 6 3� % I "�M EXP DATE 1 Z.3 �� Zd % O
sTA� aorrD #% O 2, 7�� �`� ExP n.a� j z j3 / j 2 c i o
aDD�ss: l 3�^ b�, � j� r s; li R N W crrY � c- ic R i✓�">2 sTATE fL� nl zIr 5S3.�o--
PHONE �E IL j�� 7- 22 6 c FAX C7E 3) 2� i- S 6 7 G 3S`Cl
❑ SINGLE FAMILY
❑ NEW
O TWO FAMILY �TOWNHOUSE
�REPLACEMENT
DETAILED DESCRIPTION OF WORK Q� P �� C� �7 � S ��R %��- t�� %�'12
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXT[3RES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.SQ
BATH SINKILAV FLOOR DRAINS SHOWER
BATHTUB GAS PIPING (NEED CITY LIC) � SWIMMTNG POOL
CLOTHES WASHER KITCHEN SINK WATER CLOSET
, DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35)
_ WATER METER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
WATER PIPING
WATER SOFTNER ($35)
BACKFLOW PREV. ($15)
� FOR IRRIGATION
OTI�R
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 ordinan and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an ap ric ion f�r a pe it and ork is not to start without a permit on site; that the work will be in accordance
with the approved plan in t e, � or i es review and appro}�� of pl st
SIGNATURE OF APPLICANT 'I PRINT NAME /v< < C!`t��� /Z I�I�� �S.�DATE �f� /�C �( d
APPROVAL INSPECTORS SIG A
City of Fridley
Building Inspections Department
6431 Universiry Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977