P - 48678Building
Inspections
763-572-3604
763-502-4977 FAX
DATE , P� 7 �
SITE ADDRESS �
TEIlS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
DET.
N
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTTVE 1-]-2012
O � YQUR E-MAIL ADDRESS
�L_tvG•� F
❑ OWNER �CONTRACTOR
� � � ' fYL�.7'�:�►l.�II/
. �
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STATE LICENSE # - C.
STATE BOND #
ADDRESS:�g�
PHONE �
�SINGLE FAMILY
❑ NEW
'ION OF WORK f�C
I`�r � � ��v
❑ TWO FAMILY
�REPLACEMENT
/G � �,t"�"G �
FAX
❑ TOWNHOUSE
Permit N
Received By�_
Date ' ��
��
EXP DATE
EXP B�E
�
�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NO'I'ED. FIXTURES: (INDICATE TOTAL NtTMBER OF EACH BEIAW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DR.AINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTf�S WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. (S15)
DISHWASHER LAUNDRY TRAY _WATER HEATER ($35) FOR IRRIGATION
WATER METER OTf�R
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing pe and I ac wledge that the information above is complete and accurate; that the work will be in
conformance with the ordin d codes of City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an a li t permi ork i ot to start without a permit on site; that the work will be in accordance
with the approved plan in s o ic i re� '�s�r�v w and appro 1��ans.
SIGNANRE OF APPLICANT T NAME � � v� � DATE i� O C
APPROVAL INSPECTORS SIGNAT � __ DATE _
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977