P - 42199Building
Inspections
763-572-3604
763-502-4977 FAX
DATE "' % 7 ' �(J �
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011 _ �i
YOUR E-MAIL ADDRESS,
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� OWNER �C NTRACTO
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STATE LICENSE #��
STATE BOND H �? //
ADDRESS:,�Q"
PHONE /.��'YS/X��;
�.SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
Pernut No.�%
Received By:1-""��
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,T6�'�'LIP��
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� � � EXP DATE �'�-� 3% aCJ �'„�
DATE � � ' 3 l ' .�d / (
if�'� � CITY ��� STATE1�ZIP���
FAX ,�2 � � �S!'�� �P �-� �
❑ TWO FAMILY O TOWNHOUSE
�PLACEMENT
FEES ARE BASED ON S 10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
�35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
�_C-BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER (S35)
CLOTHES WASiiER KITCHEN SINK WATER CLOSET BACKFLOW PREV. (S15)
_ DISHWASHER _ LAUNDRY TRAY _WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
Number of fixtures @ $10.00 x $10.40 = $
Number of fixtures @ a15.00 x�15.OQ —$;
Number of fixtures Q$35:00 x$35.00 =$
State Surcharge $ 5.00 .
(MIr1IMUM $40.00) Total = $ (,i1 �� ,,�
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
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1 hereby apply for a plumbing pe t d I acknowl ge t the information above is complete and accurate; that the work will be in
conformance with the ordinanc codes of tlte Fridley and with the Minnesota Construct Codes; that I undetstand this is
not a permit but only an p ' n for a pe work is not to start without a permit on e• at the work will be in accordance
with the approved plan th f wo ' es review and appr 1 of pl �� / /
SIGNATURE OF APPLIC PRINT NAME �� � d � DATE ��i ��l/
APPROVAL INSPECTORS SIGNAT 7—DATE
PLEASE NOTE: SEPARATE PERMITS ARE REOUIRED FOR BUILDWG. ELECTRICAL AND MECHANICAL WORK
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977