P - 41777Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � U � J "
STI'E ADDRESS �
THIS APPLICANT IS:
OWNER/
TENANT
CONTRACTOR
SUBNIIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
I��;i„irW�•���
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MAIL ADDRESS
❑ OWNER �CONTRACTOR
Permit No:�
Received By: �
i�te�[et�'d:� �
ADDRESS: CTTY STATE ZIP
PHONE:
STATE LICENSE
STATE BOND #
0
EXP DATE
EXP DATE
..
rxorrE 71.3 - �4 �} y- 9�'�3 FAx 7(,3 -�+L++� -'�i, z 9
�SINGLE FAMII,Y
O NEW
❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
DETAILED DESCRII'TION OF WORK � e�,�,� �-�-0���! _�Qni-t.�
FEES ARE BASED ON $10.00 PER FDCT[JRE, EXCEPT WHERE NOTED. FIXT[JRES: (INDICAT'E TOTAL NUMBER OF EAGH BELOVi�. 1►�IINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHqWER WATER PIPING
BATHTUB GAS PIPING (NEED C1TY LIC) SWiMMING POOL WATER SOFiNER ($35)
CLOTHES WASHER KITCHEN SINK WA'i'ER CLOSET BACKFLOW PREV. ($15)
� DISHWASHER _ LAUNDRY TRAY 1WATER HEATER{$35) FOR IRRIGATION
_ WATER METER _ OTf�R
Nu�b�r of �ixtures � $35.00 � X �3s.00 = �,,�5. ao
State Surchazge $ 5.00
r�rt�rnt�� �ao.00� Tor� = s y o• o0
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 cornplete and accurate; that the work will be in
conformance with the ordinances and codes the City of Fridley and with the Minnesota Constarruction Codes; that I understand this is
not a permit but only an application for a perm an ork is not to start without a permit on site; that the work will be in accordance
with the approved plan in th as� of all rk ' r quires review and approv of pl s. ,j,t
SIGNATURE OF APPLICANT ' Pj2IN1' NAME I RLr DATE__L�I����isr � �i7�
APPROVAL iNSPECTORS S G ATiJRE X�1 DATE � �K
v City af Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977