P - 47800Building
Inspections
763-572-3604
763-502-4977 FAX
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
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Permit N
Received By: i�__
Dat����d� � � ��
DATE %� ^ p—(� YOUR E-MAIL ADDRESS �j
SrrE ADDRESS � S y�-, � T`� S� A � h'" C
THIS APPLICANT IS: ❑ OWNER Ji1�CONTRACTOR
PROPERTY N�: S�, (v,�;-„-� �c,,,
OWNER/
TENANI' `�D�SS: CITP STATE ZIP
PHONE:
CONTRACTOR NA�: �0-- e I ��
SUBMIT A COPY OF � C—
YOUR STATE STATE LICENSE # (°�� y �-7 c� _ P N„` EXP DATE _ I Z- 3) - 20/
LICENSE, BOND AND STATE BOND # t/�/( -�j� j
CERTIFICATE OF EXP pATE _�- 30 -�. ��
nnv�ss: CQ �F � l I j�''cC L N' N w ci� �iZa h�Q � sTA���V z� SS3�3
INSIJRANCE
PHONE � � � � --� �o �y ��� p'SZc � FAX
PERMIT T'yPE
TYPE OF WORK:
❑ SINGLE FAMILY
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❑ TWO FAMILY �TOWNHOUSE
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❑ REPLACEMENT
DETAII,EDDESCRIPTIONOFWORI� �• • � La��. ������
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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 L SHOWER
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL — WA� PIPING
_ CLOTHES WASHER HITCHEN SINK _ WATER SOFTNER ($35)
DISHWASHER —" � WATER CLOSET BACKFLOW PREV. ($15)
— _ LAUNDRY TRAY _WATER HEATER ($35) FOR IRRIGATION
_ WATER METER OTHER
Number of f xtures (a� $10.00 � x$10.00 =$ 3�'�
ATumber af fixtures @$15.00 x$ t S.QO =$
1�Ttimber of fixtures @ $35.U0 x $35.QU = $
State Surcharge $ 5.00
S40,fl0 Tatat ° $ �
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 comptete 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 ase f all work which requires review and approval of pla .
SIGNATfJRE OF APPLICANT PRINT NAME 'T'; ,,., ' , �_ R, �/
APPROVAL INSPECTORS SIGNATi7RE P-� DATE_
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977