P - 35088Building
Inspections
763-572-3604
763-502-4977 FAX
DATE / J �
SITE ADDRESS _
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CIT� OF FRIDLEY
EFFECTIVE I-1-2011
YOUj E-MAIL ADDRESS
� �
❑ OWNER �ONTRACTOR
Permit No:
� - - - . : ��;�-T.���
� . '!��, ,� , � ��i
ADDRESS: CITY STATE ZIP
PHONE:
NAME: � T � �/�'l e tiGl
STATE LICENSE # J� %�'i `o � � C � EXP DATE � •7 `� � ° ��
STATE BOND #
ADDRESS:�
PHONE c�! I
�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
/�,REPLACEMENT
FAX
❑ TOWNHOUSE
EXP DATE -' ��
n S�� STATE�ZIP s D,�
FEES ARE BASED ON $16.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
�BATH SINK/LAV FLOOR DRAINS _ SHOWER �,WATER PIPING
� BATHTUB � GAS PIPMG (NEED CITY LIC) SWIMMING POOL _ WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK � WATER CLOSET BACKFLOW PREV. ($15)
, DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR [RRIGATION
WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LJNTIL 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 the Ciry of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a er 't and k is not to start without a permit on site; that the work will be in accordance
with the approved plan in the c all wh h quires review and appro�' 1_ f pla
SIGNATURE OF APPLICANT PRINT NAME �' � � P e �`2 fc ��'1 � � ' S � DATE /'j � �
APPROVAL INSPECTORS SI E _. DATE __ ,
V' City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977