P - 45126Building
Inspections
763-572-3604
763-502-4977 FAX
DATE t 1 - / 9 - ! �%
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CIT� OF ��DLEr1'
EFFECTI V E 7-1-2010
YOUR E-MAIL ADDRESS
SITE ADDRESS � � � �I24n��i �-d- �-i- p�' � r (/i t .4 t ��
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYrE oF wo�:
Permit No.:��'
' - - - � : '��: I
. , :` �, 11 �' '� \�` i; ��
NAME: /{�i-�-L� Jc�,oa� eratt�
ADDRESS: �j � '"( 6 l? e� �, LE.. (c,� (� (' :n.) CITY ��-'-��� :� STATE47 N ZIP ��( 3i
PHONE: �( i. J vj 1 � (�' �t 'I
NAME: �� �r : v ��_ j% t.�-- b""� c� e_(
STATE LICENSE # EXP DATE
STATE BOND # EXP DATE
ADDRESS:�(cL�I l� f'"�C�-4-� S tr,1�. CITY �1[-l�4��. STATED'i� ZIPSS��
PHONE 7 6 3 7 S�F c1. t�t � FAX
�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
r�,�.
FEES ARE BASED ON $] 0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NLTMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLQORDRAINS SHOWER WATERPIPING
BATHTUB GAS PIPING (NEED CITY LIC) 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 I acknowledge that the information above is complete and accurate; that the wark 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 the c,.�se o,f., _all�work+J�'hich requires review and approv of plans,/.�
SIGNATURE OF APPLICANT C��-�.a� !''�-�c`"':-' t°� PRINT NAME (1 C'z J 1 c- �; .n ., DATE f 1- � SI �( O
APPROVALINSPECTORSSIGNATURE , '°_________ °�-
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977