P - 42326Building
Inspections
763-572-3604
763-502-4977 FAX
DATE
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTfVE 1-1-2010
YOUR E-MAIL ADDRESS
❑ OWNER ❑CONTRACTOR
ADDRESS
CONTRACTOR NAME:��
SUBMIT A COPY OF
YOUR STATE S7'ATE LICENSE #_
LICENSE, BOND AND STA'fE BOND #
CERTIFICATE OF ADDRESS�
INSURANCE pHONE I� l�% _-
PERMIT TYPE
TYPE OF WORK:
DETAILED DES�R
SINGLE FAMILY
❑ NEW
OF�ORK
��
1 `� � �r-1=�� �/' N��c�rY
— C'in � .,_, i 7 — � �
❑ TWO FAMILY
�REPLACEMENT
FAX
O TOWNHOUSE
t
Permit No.: 1 �`
Received By:�
���ec��
A
EXP DATE r Z�' 'Z C7
EX P qATFJ9. �� I. �f� � C� �
�� ��SJTATE�
� [.1"7 �-r _ / �
FEES ARE BASED ON $] 0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH �I.OW). MINIMUM FEE
$35.SQ. /
BATH SINK/I.AV FLOOR DRAINS SHOWER � WATER PIPiNG
BATHNB GAS PIPING (NEED CITY LIC) SWIMMiNG POOL WATER 30FTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSE7' BACKFLOW PREV. ($]5)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGA770N
WATER METER OTHER
THIS IS AN APPLtCATION 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 wil] be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Constraction 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 c�se of:al�ork which requires review and approval of p(ans. �r'
�_
SIGNATURE OF APPLICANT�--� �� �'�..�� '""( ^ PRINT NAME� �^'� � � � �j � V
� t ^J DA7'E � `�� �}�' 1 L`f
City of Fridley
Building Inspections Department
6431 University Avenue NE, Frid]ey, MN 55432
763-572-3604
FAX: 763-502-4977