P - 47801Building
Inspections
763-572-3604
763-502-4977 FAX
DATE (p"��i
STTE ADDRESS S tf .
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
Permit No.
Received By:
CITY OF FRIDLEY Dat � �'
EFFECTIVE 1-1-2011 ����� , � � � ��
YOUR E-MAIL ADDRESS G}%c; v�• . L�N Jn,,,�! n � rA �` �. r� � I ,.e,�
1
❑ OWNER �CONTRACTOR
N.�E: CG I K}' r� /•i f� 1+.J1 �__
ADDRESS: CITY
PHONE:
NAME: /-�(Sr
STATE LICENSE #
Tn� ztr,
L
EXP DATE ��_'� �^ 1'Z
STATE BOND # �l� �( -,rt� j� EXP DATE i- 30 ^ 2od'Z
ADDRESS:�j � C�` y�,nJ ,(� f �„J CITy G,,,, • STATE ^�_ZIP S�� ��
PHONE �%c.�` ° ( � `� -- Cn�%[ O FAX �% Co� - Y2.%� 'L% �j"io
❑ SINGLE FAMILY
�
❑ TWO FAMILY �OWNfIOUSE
❑ REPLACEMENT
DETAILED DESCRII'TION OF WORK �tig� o� f.e���
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED.
S35.50.
� BATH SINK/L,AV FLOOR DRAINS
_ BATHT[JB GAS PIPING (NEED CTI'Y LIC)
_ CLOTHES WASHER KITCHEN SINK
_ DISHWASHER _ LAUNDRY TRAY
FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
Number of fi�ctuces �7a, $10.Q0 � x$1�.OU =$ 3�°-=
Number of fixtttres @ $15.Q0 x $15.44 = $
Number of fixtures @ $35.OE? x $35.UQ= $
State Surchar�e $ ' S.04
�NIIlYI1V1Ul1�i 540.00) Tatal = $ � �
� SHOWER
SWIMMING POOL
� WATER CLOSET
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 wark is not to start without a permit on site; that the work will be in accordance
with the approved plan in the cas of all work which requires review and approval of plan
SIGNATURE OF APPLICANT e PRINT NAME '-�,�__�_� " DATE �_�-� r
APPROVAL INSPECTORS SIGNATURE _ . —
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977