P - 39362Building
Inspections
763-572-3604
763-502-4977 FAX
DATE
SITE ADDRESS _
TENANT
PROPERTY
OWNER/
TENANT
PLUMBING
COMMERCIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDFtESS
SU[TE NO.
NAME: /E/ C.1 i'� ��C'� � �,� `/'� �1 �.
ADDRESS: ()Sc. L� - 1�..1 IJ CI �-'A� �
PHONF. %r, ! � �— C9 � �P .-- (` � fi _
Permit No.: �iLi
Rec ' �:
Date�ec' d:
ATF.��%�c�IP.
CONTRACTOR NAME:1�.,`,J �+ �_. s. U�`Y�'' 4 G
SUBMIT A COPY OF STATE LICENSE # � �,�j f(„_ EXP DATE �C� ��
YOUR STATE
LICENSE, BOND AND PLUM$ING BOND #"�—�L._. �� �� `� EXP DATE _ � U(�
CERTIFICATE OF ADDRESS:� C>S C L h��i"�`l.�?I_. ry L/ � CITY_�O L„ �-�'�. STATE�_�ZIP ` s
INSURANCE pHONE� \ "� - �� �5 l3 �� FAX � : � �-{ Z /
PERMIT TYPE
TYPE OF WORK:
❑ INSTITUTIONAL
❑ TOWNHOUSE
❑ NEW
DETAILED DESCRIPTION OF WORK
��� o t/1 n,C1 L�
_ CLOTHES WASHER
_ DISHWASHER
_ DRINKING FOUNTAIN
_ FAUCET
FLAMMABLE WASTE TANK
Total Job
Valuation
Permit Fee
Surcharge
Total Due
�A�ii}.
_ FLOOR DRAINS
_ GAS PIPING
_ GREASE TRAP
_ KITCHEN SINK
_ LAUNDRY TRAY
_ LAVATORY
$ �_
$ .�
$35��
��� ULTI-FAMILY
`Q COMMERCIAU[NDUSTRIAL
�REPLACEMENT
.
_ RPZ VALVE
BACKFLOW PREV
_ ROOF DRAINS
_ SHOWER
_ SLOP SINK
_ SWIMMING POOL
❑ SWIMMING POOL
❑ OTHER
❑ ALTERATION/REMODEL
URINAL
�WATER HEATER
_ WATER METER
_ WATER PIPING
_ WATER SOFTENER
_ WATER CLOSET
A(I fees are based on valuation, including the cost of labor and materials.
(1.25% of Job Valuation ! Minimum fee: $35)
Valuation X .0005 or Minimum .50
Make Checks Payable to: City of Fridley
��
�'�
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 a work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case of all wo��equires review and approval of plans.
SIGNATURE OF
AL INSPECTOR
NAME:
City of F�dley Building Inspections Department
6431 niversity Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
DATE: � /i�