P - 40836Building PLUMBING PermitNo:�� � g �
Inspections RESIDENTIAL APPLICATI�N Received By: �' •
763-572-3604 CIT� UF FRIDLEY ���a: � � 1
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE G YOUR E-MAIL ADDRESS �•�- �I� — iM�V�. .[, '� r'l
si�.�DxESS SC�.`f 1J �.J�.�r�µ� �4�y
THIS APPLICAN'I' IS: ❑ OWNER �ON"I'RACTOR
PROPERTY ��: r
Ow1�TER! aapxESS: ��� r (,J .`��c.� �,.. t�s cITY f r'� le � sTAT�J�z� 5�`13a
TENANT Pxor�: ?6� � �3f3 OI�.S I
CONTRACTOR Nt�ME: �l�- ��.,�:�,bi.� � -�(�L�.r'��
SUBMIT A COPY OF STATE LICENSE #_ S'� �^{r�O �%� EXP DATE
YOUR STATE
LICENSE, BOND AND STATE Bc7ND # EXP DATE
CERTIFICATE OF e,ppg�gg. C{diu�o ��htx� � ��:�P CITY �ar�IC�e� Ii��Ieu STATE � ZIP�
INSURANCE pHONE 7Co_3 �-C`'f.� �%��'ci FAX ?6� �KC� �OI
pERMiT T.YP�, INGLE FAMILY ❑ TWO FAMII..Y � TOWNIIOUSE
TYPE OF WORK: � ��`' �REPLACEMk;N'I'
DETAILED DESCRfIPTION OF WORK v�•�v � s ✓ a/' �.P ��sr, � act ✓�
'�' C R_,�s� I utrrt..J `C �-t9,�.�C'. �' � Q.
FEES ARE BASED ON $] 0.00 PER FIXTCJRE, EXCEPT WF�'..RE NOTED. FIX1'T)RES: (INDICATE TOTAL NUMBER OF EACA BELOV�. NIIIVIMUM FEE
$35.50.
BATH SINK/I,AV FLOOI2 DRAINS L SHOWER WATER PIPING
BATFITUB GAS PIPING (NEED CITY LIC) SWIMNIING POOL WATER SOFTNER ($35)
T GLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAt7NDRY TRAY WAT'�R iiEATER ($35) � FOR IRRIGATION
WATER METER OTfiER
r,;�; �
�illYl�lll�' O��tlt'C.4 � �� �.�! Jt ���.�i' � � r
Number of fixtures @$15.00 x S15_00 -$
Numbea' of fixtures @ $35.� x $35.00 = $
State Surcharge $ 5,00
Li
rZINIlHUIVI 540.00 Tota1= $
THI3IS AN APPLICATION FOR A P�;RMIT-NOT VALID UNTIL PRC�ESSED
I hereby apply for a plumbing permit and I acknowledge that the infosmation above is complete and accurate; that t1�e 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 permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in th ork which requires review and apprqval of plans,
SIGNATURE OF APPLICANT' �����--- PRIN`I' NAME Jb� T r.r.�`..c.ti DATE � 023
APPROVAL INSPECTORS SIG. DATE
PLEASE NOTE: 5EPARATE PERMTTS ARE RE UI1�ED FOR BUILDING EL�,CTRICAL AND MECHANTCAL WORK
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977