P - 46266Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �D � I
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY Np
OWNER/
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
TENANT ADD�SS:
CONTRACTOR NAME: R� vu-
SUBMTT A COPY OF
YOUR STATE STATE LICENSE #,
LICENSE, BOND AND STATE BOND #_
CERTIFICATE OF ADDRESS:�
INSURANCE
� 2
-.�D2-
PHONE �
PERMIT TYPE J��GLE FAMILY
�rYrE oF woRx: I � NEW
DETAILED DESCRIPTION OF WORK
YOUR E-MAIL ADDRESS
❑ TWO FAMILY
�}�EPLACEMENT
CITY
FAX
� TOWNHOUSE
Permit No.
Received B
I��- '�
EXP DATE
EXP DATE
��STATEr' { ZIP S�% 2-
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELO�. MINIMUM FEE
$35.50.
BATH SINK/LAV FLOORDRAINS SHOWER WATERPIPING
BATHTUB GAS PIPING (NEED QTY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATERCLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LiNTIL PROCESSED
I hereby apply for a plumbing permit and I ackno edge t a the information above is complete and accurate; that the work will be in
conformance with the ardinances and codes of the o F dley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and k s not to start without a permit on site; that the work wiil be in acc rdanc
with the approved plan in th of a wor ich r i s review and approval of lans/���
SIGNATURE OF APPLICANT P��'�I�tE ��/�i� udt�i✓,'�ry' DATS �
APPROVAL INSPECTORS SIGNATURE �/ �-DaTE
�� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977