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Building PLUMBING Permit No.:Pe-2-2--
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date Rec'd: 5- /7kz 0
763-502-4977 FAX EFFECTIVE 06/I4/2018
DATE �D '-1 2 YOUR E-MAIL ADDRESS. l ��. (r.(.l l.•L I I / P• C-O n')
SITE ADDRESS 0( Ln n t-
THIS APPLICANT IS: El OWNER CONTRACTOR
PROPERTY N A M E: M I cm 0 0 , 7
OWNER/ ADDRESS: w 1, CITY STATE Ya IP55�32_
TENANT PHONE: 1 Z.2
CONTRACTOR NAME: t Ctjh
SUBMIT A COPY OF
YOUR STATE STATE LICENSE PC# 2, EXP DATE
LICENSE,BOND AND STATE BOND M/B,,# EXP DATE
CERTIFICATE OF ADDRESS: 4 U l� CITY �� Q.U,� STATE ZIP55105
INSURANCE ', FAX
PHONE
PERMIT TYPE NGLE FAMILY ❑TWO FAMILY ❑TOWNHOUSE
TYPE OF WORK: ❑NEW REPLACEMENT
DETAILED DESCRIPTION OF WORK
FEES ARE BASED ON$10.00 PER FIXTURE,EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW).
_BATH SINK/LAV _FLOOR DRAINS _SWIMMING POOL —WATER PIPING
_BATHTUB _KITCHEN SINK _WATER CLOSET WATER SOFTNER($35)
CLOTHES WASHER _LAUNDRY TRAY `X WATER HEATER($35) BACKFLOW PREY.($15)
—DISHWASHER _SHOWER _WATER METER FOR IRRIGATION
OTHER
Number of fixtures @$10.00 x$10.00=$
Number of fixtures @$15.00 x$15.00=$
Number of fixtures @$35.00__L x$35.00=$
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State Surcharge $_ 1.00
i
MINIMUM$35.00 plus surchar a Total=$ Lp, ()U
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 City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application f ermi n o is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case o I1 wo i quire review and approval of plans.y
SIGNATURE OF APPLICANT MI�J��I L1 InOI 1 I�, DATE 1' 22
APPROVAL INSPECTORS S1GNA E DATE /
PLEASE NOTE: SEPARAT ITS QUIRED FOR BUILDING,ELECTRICAL AND MECHANICAL WORK
City of Fridley
Building Inspections Department
7071 University Avenue NE, Fridley,MN 55432
763-572-3604 FAX: 763-502-4977