P - 47803Building
Inspections
763-572-3604
763-502-4977 FAX
DATE (o/ �j
SITE ADDRESS �y
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
0
STATE LICENSE #
STATE BOND #
❑ SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
YOUR E-MAIL ADDRESS
�WO FAMILY
L9'REPLACEMENT
Permit No.
Received By:e d�
D���: �;lC11� � � �' ��,
– " ' ✓ STA
EXP DATE
EX AT
_CITY STA7'I
FAX
❑ TOWNHOUSE
FEES ARE BASED ON $]0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
_, BATH SINKILAV FLOOR DRAINS
— BA��B GAS PIPING (NEED CITY LIC — SHOWER
_CLOTHESWASHER KITCHENSINK � —SWIMM[NGPOOL
_ DISHWASHER LAUNDRY TRAY WATER CLOSET
— �ATER HEATER ($35)
�� _ WATER METER
_ WATER PIPING
_ WATER SOFTNER ($35)
_ BACKFLOW PREV. ($IS)
FOR IRRIGATION
_ OTHER
_ ..:. �, ,.. .. _; �:;�: � .���:;�,
HIS IS AN APPI.ICA710N FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby 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 code of the City of Fridley and with the Minnesota Construction Codes; that I underst nd this is
not a permit but only an appli ation f p wor ' t to start witho a perm' site; that the or wi 1(� in c ordance
with the approved plan in th ' w and app " a o � j
SIGNATURE OF APPLICANT � �
APPROVAL INSPECTORS S ATURE INT NAME E /
�
��` . ����i�":�� , a�,�� ��,��7"�,f�i�* •:: ,��r,�r..:x;�,�,7.�r„s=:. �..�.�,,,_ �._ . ..,,. __ ., _ DA7'E
��,r_ _ � l
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977