P - 47291Building � p�,�T1�B�N�
Inspections �5����T�•��� ��������,�QN
763-572-3604 ��,�,� �� ������
763-502-4977 F�,X
EFFGCTIVi 1-1-2071
DATE �� � �
SITE ADDRESS '
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
YOUR t-MAIL ADDRESS
I— L � �
� -�!
❑ OWNER �ONTRACTOR
NAME ��
ADDRESS � �
PHONE:
NAME: �jj� � � j
STATE LICENSE #
STATE BOND i!
ADDRESS:� � f' � ' ��
PHONE �= . �,�
�SINGLE FAMILY ❑ TWO FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
�REPLACEMENT
CITY
Permit No.: �
�Gd�`�����'
��� _
Date ec'd:
A
EXP DATE
EXP DATE
I'Y � ' '•(i+ STAT ZI� 2.
FAX �(Q. "��j '� Z�%%�3l�
❑ TOWNHOUSE
FEES ARE BASED ON $] 0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
_ BATH SINK/LAV FLOOR DRAINS SHOWER
_ BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL — WATER PIPING
_ CLOTHES WASHER KITCHEN SINK — _ WATER SOFTNER ($35)
DISHWASHER — WATERCLOSET BACKFLOW PREV. ($15)
— _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
� , r �� �« _
_ WATER METER _ OTHER
z� �....� x. ,....� .,.�.�„ „�..�.._ . „
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 app 'cation for a pertnit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in t �' all w which requires review approv 1 ans��
SIGNATURE OF APPLICANT " P AME
APPROVAL INSPECTORS SIGNATIJRE DATE �� !> //
�T.�+%d,�'"hF�%#��"4 �- .;��+.TS-�'"n�� ^t���n� . �. ; _ DATE _ / • —
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977