P - 45115-Building
Inspections
763-572-3604
763-502-4977 FAX
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 7-1-2010
Permit No.:
Received By:
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DATE � r j�` t� YOUR E-MAIL AD�DlRESS ✓ �
SITE ADDKES5 �j`) ,`'>� �JC. �''� ��-ri � �Q.. IG--Gt
THIS APPLICANT IS: ❑ OWNER [�CONTRACTOR
PROPERTY IN
OWNER/ A
TENANT
A
CONTRACTOR NAME: �^►tiemr� ! ICril7I
SUBMIT A COPY OF T'�"�'�Q��""-�`�
Youx sTA� sTArE LicErrsE a ## fi1770»PM EYr �ATE f 2- —� 1�' 1�
LICENSB, BOND AND STATE BOND # �I �a36J'�I r�'0 EXP DATE �`
CERTIFICATE OF ADDRESS: 36TO ' CITY STaTE zIP
1NSURANCE pHONE �n' FAX
PERMIT TYPE �SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW �PLACEMENT
DETAILED DESCRIPTION OF WORK v�C.�t-i/Y �G�'�-W� V�� C:� C�,'_V'�-Q�
FEES ARE BASED ON $10.00 PER FIXT'URE, EXCEPT Wf�RE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/I.AV FLOOR DRAINS SHOWER WATER PIPING
� BATHTUB GAS PIPING (NEED CITY LIC) ^ SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATEK 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 I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the Ci of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for p it an work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case rk e ' w nd appra`val of plans. .
SIGNANRE OF APPLICANT NAME �,,lC�.,V"Y?�'� ����DATE �`" � � �� �
City of Fridley�
Building Inspections Department
6431 University Avenue NE, Fridley, NIN 55432
763-5'72-3604
FAX: 763-502-4977
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