P - 48213Building
Inspections
763-572-3604
763-502-4977 FAX
DATE o< �10. ✓l I �
SITE ADDRESS �
T'HIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2012
.. X12UR E-IYIAIL ADDRESS _ �Ve rC°��/ C`: �'"
❑ OWNER �60NTRACTOR
ADDRESS: CITY,
PHONE:
NAME� � S P�iXVI MSI C
STATE LICENSE # U `� 1
STATE BOND # O O
ADDRESS: � S S CITYs
PHONE ��3- o� .S �� �i� % FAX
SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
�REPLACEMENT
❑ TOWNHOUSE
G
Permit No.:
Received By:�
��'�eJ� �v 2 �° � u I �
EXP DATE
EXP D TE
ap��S
� � /� M
ATE ZIP_
Dec �a
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMtJM FEE
�$ 5.50.
TH SINK/LAV _FLOOR DRAINS SHOWER WATER PIPING
�ATHTUB GAS PIPIi�IG (NEED CITY LIC) SWIIvIlvIING POOL _ WATER SOFTNER ($35)
CLOTI-IES WASHER KITCHEN SINK �SWATER 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 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 �� which requires review and appro-.}' al of plans. '_Q �-� �} 3�q„-� a
SIGNATUREOFAPPLICANT ��!���i''�J PRINTNAME JPr�" P�,T�' � DATE il.. I
APPROVAL INSPECTORS SI A R DATE'
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977