P - 42181Building
Inspections
763-572-3604
763-502-4977 FAX
DATE 4 • P `�U '
SITE ADDRESS O��
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTI V E 7-1-2010
❑ OWNER
NAME: O Y
ADDRESS:�
PHONE: ,
YOUR E-MA►L ADDRESS
Permit No.:
Received By:
� r 1 � -
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # � hliance Cot�nections Inc EXP DATE
YOURSTATE
LICENSE, BOND AND STATE BOND # '' ����* ����' •r EXP DATE
CERTIFICATE OF ADDRESS: Ci,sl....�,�.. cs�w� �� i� �STATE ZIP
INSURANCE pHONE _ _ .�. �.. . �_ _ �
PERMIT TYPE ��NGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW ��PLACEMENT
DETAILED DESCRIPTION OF WORK W � / W�
FEES ARE BASED ON $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 P1PING
BATHTUB GAS PIPWG (NEED CITY LIC) � SWIMMING POOL � WATER SOFTNER ($35)
CLOTHES WASHER � KITCHEN SINK ` WAT'ER CLOSET BACKFLOW PREV. ($15)
DISHWASHER LAIJNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
— WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and [ 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 r a permit and work is not to start without a permit on site; that the work wiii be in accordance
with the approved plan in the case of all ork hich requires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME DATE
APPROVAL INSPECTORS SIGNATURE „( _ Od� . _ _...,...�.,.
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977