P - 42174Building
Inspections
763-572-3604
763-502-4977 FAX
DATE Z'�l�—ZC%j
S[TE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
� �� i � f 'C.J
❑ OWNER ❑CONTRACTOR C� �i'�/ OW
ADDRESS: CITY
PHONE:
- • . - •- /� - - . ? _ _ r— e _ .-,r I �
Permit No.:
Received By:
Tl,.�,. D,.,.�.J.
TATE ZIP
STATE LICENSE # V V EXP DA"C6
STATE BOND # EXP DATE
ADDRESS: Cl (� C1TY �<p,n,�f STATE �✓ ZIP ssz�Yc
PHONE FAX
�INGLE FAMILY
�NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
❑ REPLACEMENT
�
❑ TOWNHOUSE
�_ _ r
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
� BATH SINK/LAV FLOOR DRAINS SHOWER � WATER PIPING
t BATHTUB GAS PIPING (NEED C[TY LIC) � SWiMMING POOL WATER SOFTNER ($35)
� CLOTHES V✓ASHER _ KITCHEN SINK 'Z,WATER 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 co s of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applicatio a ermit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the e f � ork whic requires review and apR�� I o ans.
SIGNATURE OF APPLICANT PRINT NAMb,J O C\ (��t[Y\U` !�/� DATE ' O
APPROVAL INSPECTORS SIGNATU t. �1 . ° ne�rF ✓ �� ..� _. �
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977