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Building
Inspections
763-572-3604
763-502-497'7 FAX
DATE � � °2 / � �
S1TE ADDRESS ��
TENANT /4L' <
PROPERTY
OWNER/
TENANT
PLUMBING
COMMERCIAL APPLICATION
CITY OF FRIDLEY
EFFECTTVE 1-1-2012
/ YOUR E-MAIL ADDRESS � ��� T/ `/"1'
J
,��fi�n ����se
ADDRESS: CITY,
PHONE: � 3 `�.S�7Z ✓%�%��
SUITE NO.
Permit No.:
Received By;
Date Rec'd:�
ATE ZIP,
CONTRACTOR NAME � � � ✓� '
SUBMIT A COPY OF STATE LICENSE #�� a,+Z `/�i`'� + EXP DATE �e?' �� " a bl �
YOUR STATE
LICENSE, BOND AND PLUMBING BO/ND # EXP DATE
CERTIFICATEOF ADDRESS: /b �/ �'���' °�'� l�� CITY �� �vW� STAT �_ZIP�
INSURANCE pHONE ��.Z — � � �I " � 3 � o FAX
PERMIT TYPE � �STINTIONAL �MULTI-FAMILY ❑ SWIMMING POOL
❑ TOWNHOUSE � COMMERCIALQNDUSTRIAL ❑ OTHER
TYPE OF WORK• � NEW ��PLACEMENT ❑ ALTERAI'ION/REMODEL
DETAILED DESCRiPTION OF WORK
_ CLOTf�S WASHER
_ DISHWASHER
DRINKING FOUNTAIN
_ FAUCET
FLAMMABLE WASTE TANK
_ FLOOR DRAINS
_ GAS PIPING
_ GREASE TRAP
_ KITCHEN SINK
_ LAUNDRY TRAY
_ LAVATORY
,c c_� �� � .S'rro r�
_ RPZ VALVE
BACKFLOW PREV
_ ROOF DRAINS
_ SHOWER
_ SLOP SINK
SWIMMING POOL
URINAL
� WATER HEATER
_ WATER METER
_ WATER PIPING
_ WATER SOFTENER
_ WATER CLOSET
�:� �•��:������ �.� �,�,.� .,�.. , ,..� ..___ _
Total Job $/ C� v All fees are based on valuation, mcluding the cost of labor and materials.
Valuation
Permit Fee $�.vU (1.25% of Job Valuation / Minimum fee: $35)
Surcharge $ _��7 Valuation X.0005 or Minimum .50
Total Due $ G�, �� 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 o e City of ridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a p it and w 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 w which r ires review and approval of plans.
t
SIGNATURE OF APPLICANT : ` PRINT ME���j ` Y`'Ca�! DATE: ��7`��
-- - - ---- � O s � /�w J �.� � ��T. . nA� � / /i+'�-'
City of F�idley Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977