P - 40828Building
Inspections
763-572-3604
763-502-4977 F
DA1'E j /
SITE AD SS _
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE i-I-2011
/ J -." ,7 � �'
� OWNER
NAME:
ADDRESS: �-°
PHONE: %613�' ,S
YOUR E-MAIL ADDRESS
J� �
�ONTRACTOR
� ,
��� �/��� CITY
7/— CJ/ri7�
STATE LICENSE # G�,S �7j,` Y/'Yi
STATE BOND tt 9�i � 7/
ADDRESS: � %f� " ��T G,�i /�/ CITY
PHONE %�3 �,5��'/-.}',JLJGC FAX
PERMIT TYPE � SINGLE FAMILY
TYPE OF WORK: I� NEW
DETAILED DESCR[PTION OF WORK
O TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
Permit No.:
_ �
Received By:
���I4 �� ���
�P,.�_STATE�ZIP�
�
EXP DATE � 3% I �
�XP DATE
.� .� STAT�ZIP.
a
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
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
_CLOTHES WASHER KITCHEN S1NK WATER CLOSET BACKFLOW PREV. ($IS)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _OTHER
TH[S 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 and work is not to start without a permii on site; thai the work will be in ac ordance
with the approved plan in th �f �a� work h�i reQuires review and approval of pl�ns. �
SIGNATURE OF APPLICANT ���'��6.�.�/�z.��';�%�L*� PRINT NAME_.�{1 L L G�"O�%G � DATE 2 7 l%
APPROVALINSPECTORSSIGNATURE ner�
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977