P - 42218Building
Inspections
763-572-3604
763-502-4977 FAX
DATE lY -1 l.
SI7'E ADDRESS _
THIS APPLICANT IS:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTTVE 1-1-2010
YOUR E-MAIL ADDRESS
� OWNER 1�ONTDAC70R
PROPERTY NAME:_
�W�� ADDRESS:
TENANT
CITY
Permit No�v � i
Received By:�
r�,.�.. n ,.,, � a . ..
STA'
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE STATE LICENSE # EXP DATE
LICENSE, BOND AND STATE BOND # �n� a � EXP DATE
CERTIFICATE OF ADDRESS: �7hako.pee, MN 55378►TY STATE ZIP
INSURANCE pHONE �5,2�i,Q,�•'�W�!3 FAX
PERMIT TYPE
TYPE OF WORK: I� NEW
FAMILY ❑ TWO FAMILY O TOWNHOUSE
DETAILED DESCRIPTION OF WORK
❑ B�PLACEMENT
�
1.lJ►�i 1
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/I.AV FLOOR DRAtNS SHOWER WATER PIPING
BATHTUS GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOF7'NER (S35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) � FOR IRRIGATION
WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
�
I hPreby 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 work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the c e of aal work fiich r uires review and approval of plans.
SIGNATURE OF APPL]CANT PRINT NAME_��� C�' DATE v/ I�� �o
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977