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Building PLUMBING Permit lvo.: ��)1��3���
Inspections RESIDENTIAL APPLICATION Received By:�
763-572-3604 CITY OF FRIDLEY D��°l�C� V 0� 2� i
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE 1 c�-a� ` 1� YOUR E-MA^IL A`DDRESS
SITE ADDRESS � � � � ��� r,> � ► v �
THIS APPLICANT IS: O OWNER (j1E�iQTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIrICATE OF
INSURANCE
PERMIT TYPE
ADDRESS: � �/� L-J�y1 �;" f'�� CITY.
PHONE: �� L`'j _ �CD.� "' � � J �i ,
NAME: �
STATE LICENSE #
EXP DATE
STAT���IPy�3�
STATE BOND # EXP DATE
ADDRESS: � � � 4�` CITY �'� ��Li; ►� STATE %jiY�IP.
PHONE L,Q `k L FAX
TYPE OF WORK: I� NEW
FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
DETAILED DESCRIPTION OF WORK
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
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL
CLOTHES WASHER KITCHEN SINK WATER CLOSET
� DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35)
WATER METER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
WATER PIPING
WATER SOFTNER ($35)
BACKFLOW PREV. ($15)
FOR IRRIGATION
OTHER
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 permit on site; that the work will be in accordance
with the approved plan in the case of all work w' �,�q� es eview and appro a of plan . �(�., �,,� %
SIGNATURE OF APPLICANT C�iGG%�/� PRINT NAME �� C`J�� ` DA �' !• ��'` �
APPROVAL INSPECTORS SIGNATURE DATF.
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
PLEASE 5END PERMI'I'
TO �IOME O��VNER! !