P - 42158Building
Inspections
763-572-3604
763-502-4977 FAX
DATE `J/
SITE ADDRESS �
TENANT
PROPERTY
OWNER/
TENANT
PLUMBING
COMMERCIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE i-1-2011.
YOUR E-MAIL ADDRESS /,r�I`E7 'i � G
�� .���. �--r`�. �`l f/ F ��� �- ��
NAME:
ADDRESS:
0
SUITE NO.
Permit No
Received 1
Date RecT
CONTRACTOR NAME: (/�It��.SIJ/'1% p J �G{Y�N�, /�'YG
SUBMIT A COPY OF STATE LICENSE #_ ,`-j �'75 � EXP DATE
YOURSTATE
LICENSE, BOND AND PLUMBING BOND # EXP DATE
CERTIFICATE OF ADDRESS. � � � CITY %�✓I�U�
INSURANCE � ,� � . i , _ � , �. ,
PHONE
PERMIT TYPE � INSTINTIONAL
❑ TOWNHOUSH
TYPE OF WORK: I� N��'
DETAILED DESCRII'TION OF WORK
_ CLOTHES WASHER
_ DISHWASHER
_ DRINKING FOUNTA(AI
FAUCET
_ FLAMMABLE WASTE TANK
� FLOOR DRAINS
_ GAS PIPING
_ GREASE TRAP
_ KiTCHEN SINK
_ LAUNDRY TRAY
_ LAVATORY
Total Job $
Valustion
❑ MULTI-FAMILY
❑ COMMERCIAL/[NDUSTRIAL
�PLACEMENT
_ RPZ VALVE
BACKFLOW PREV.
_ ROOF DRAiNS
_ SHOWER
_ SLOP SINK
_ SWiMMING PQOL
2�/GC. G n.lv. r�t-sv °�
�STAT��ZIP
_ /�—�/ �!
�STATE �� �ZIP�
❑ SWIMMING POOL
❑ OTHER
❑ ALTERATION/REMODEL
URINAL
c 7�tlGATER HEATER
_ WATER METER
_ WATER PIPING
_ WATER SOFTENER
WATER CLOSET
All fees are based on valuation, including the cost of labor and materials.
Permit Fee $ 3 5. � (125% of Job Valuation / Minimum fee: $35)
Surchazge $ j, i%� Valuation X.0005 or Minimum .50
Total Due $��• oO 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 applic ' n for a permit and work is not to start y�thout a permit on site; that the work will be in accordance
with the approved plan in the ase of all work which requires review and�r�p�roval of plans.
SIGNATURE OF
�
City of Fridl� Building Inspections Department
6431 Univ sity Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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