P - 46712Building
Inspections
763-572-3604
763-502-4977 FAX
PLUMBING
COMMERCIAL APPLICATION
CITY OF FRIDLEY
EFFECI'IVE i-1-201 L
DATE ( �'-G( -�( YOUR E-MAIL ADDRESS
SITE ADDRESS CG3� %� � .S
TENANT �- � __ SUITE NO.
PROPERTY
OWNER/
TENANT
PHONE:
0
� i � . _
Permit No.:
Received By:
D���c��
ATt!// ZIP,
CONTRACTOR NAME: ` �
SUBMIT A COPY OF STATE LICENSE # D(� {D EXP DATE I��3I'� % d�-
YOUR STATE
LICENSE, BOND AND PLUMBING BOND #% C1 b 6� L/ 3,�j` j�-� EXP DATE _��Gl
CINSUIRANCB F ADDRESS: � I GI/ �Q ,ep-yLp ,if � CITy ,L�L},i,,,�p STAT�'!_ / ZIPss�7'4��
PHONE%�d3 '-%p`�" �S �o b FAX _�G 3' 7�� O S 03
PERMIT TYPE
TYPE OF WORK:
�,
❑ INSTITUTIONAL
❑ TOWNHOUSE
❑ NEW
ON OF WORK �
�e3 T,�� � 3 0 �
_ CLOTHES WASHER
_ DISHWASHER
_ DRINKING FOUNTAIN
_ FAUCET
_ FLAMMABLE WASTE TANK
_ FLOOR DRAINS
_ GAS PIPING
_ GREASE TRAP
_ KITCHEN SINK
_ LAUNDRY TRAY
_ LAVATORY
Total Job $ �
Valuation �QD�� p�
Permit Fee
Surcharge
Total Due
�4ULTI-FAMiLY
� O COMMERC[AU[NDUSTRIAL
❑ REPLACEMENT
_ RPZ VALVE
BACKFLOW PREV.
_ ROOF DRAIN3
_ SHOWER
_ SLOP SINK
_ SWIMMING POOL
� SWIMMING POOL
❑ OTHER
�K4LTERATION/REMODEL
�... ��'L�v�._ .�/�+
_ URINAL
_ WATER HEATER
_ WATER METER
_ WATER,PIPING
_ WATER SOFTENER
_ WATER CLOSE?
All fees are based on valuation, including the cost of labor and materials.
$ 3� (1.25% of Job Valuation / Minimum fee: $35)
$ � Valuation X .0005 or MiniRr►um .50
$� �`� Make Checks Payable to: City of Fridley
THIS IS AN APPLICATION FOR A PERMTT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; thatt 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 �vhich requires review and approval of plans.
SIGNATURE OF APPLICANT :
APPROVAL
PRINT NAM��'e`I'ny L- ��'�k'� �S DATE: ��^� ��
�.liC/ l DATE: ���?
City o uilding Inspections Department
� 643 ' ersity Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977