P - 48297Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � - � � I
SITE ADDRESS
T'HIS 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
CITY OF FRIDLEY
EFFECIIVE 1-1-2012
YOUR E-MAIL ADDRESS
❑ OWNEIt
Permit No.: � ��'^'� � ��
Received By:
Date Rec'd: � �'"��
ADDRESS: CITY STATE ZIP
PHONE:
STATE LICENSE # EI - � J EXP DATE �.� � 3 �"�O /��
STATE BOND # 1, Lf EXP DATE /� -3� - e%%��
ADDRESS: S�Da(� �i py►.� CITY r�ntt STATE/'?n/ZIP 33��7Y
PHONE %1��3 "o�� S � tL� �. FAX %Ls3- � ��f '�S S C:�/
�SINGLE FAMILY
�
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
❑ REPLACEMENT
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXNRES: (INDICATE TOTAL NUMBER OF EACH BELOW). MININNM FEE
$ .50.
� BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
� BATHTUB _ GAS PIPING (NEED CITY LIC) SWIMMING POOL _ WATER SOFTNER ($35)
CLATf�S WASHER KITCHEN SINK Z WATER CLOSET BACKFLOW PREV. ($15)
DISHWASHER LAUNDRY TRAY _WATER HEATER ($35) FOR IRRIGATION
WATER METER O'THER
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 complete and accurate; that the work will be in
conformance with the ordinances and codes of the C' of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applica ion or rmit and rk ' not to start without a permit on site; that the work will be in accordance
with the approved plan in the c e o a w k whic req 'res r view and approyal qf pla�s. t
SIGNATURE OF APPLICANT PRINT NAME -�vsl2 �(/�z.� r; Dn� J�—l�
APPROVAL INSPECTORS SIG URE / /I�,/ �-� _ DATE �---i�
«-City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
�4 l�