P - 42229Bui�ding
Inspections
763-572-3644
763-502-4977 FAX
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SITE ADDRESS _�
THIS APPLICANT 1S:
PROPER't'Y
O'WNER/
TENANT
BUBMlT A COPY OF
YOUR STATE
LlCENSE, BUND AND
CERTIF[CA'fE OF
INSURANCE
PERMiT TVPE
TYPE OF WORK:
PLIJIVIBI�TG
RESIDENTIAL APPLICATIUl�
CiTY U�' FRIDLEY
EPFEC3'[VE 1-1-20IU
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STATE f.tCENSE fJ_
STATE 80ND #
ADDRESS:��
PHONE�
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Permit No..�} �� �(� �
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Date Rec'd•
EXP AATE 1
EXP DATE �
FEES ARE BASED UN $10.00 PER F[XTUR6, CXCCPT W[iERE NOTED. FIXTUEtES: (INDLCATE TOTAL NUM(BER OF EAC'H Bp,OVi�, MiidIMUM FEE
L35.50.
BATH SINK/LAV _FLOpR DRAITTS SHOWER WATER p1p1N(;
� Br1fHTUB _ GAS PIPING (VEED CITY LIC) SW[MbIINti PppL WATER SOFT'hFER (S33)
' CLOTIiES WASIIER _ KTfCFIE[J SINK � WATE[i CLOSE7 BACKFLOW PRfiV_ (S l3)
T�1SH WASHER _ LAUIrARY TRAY �WATER HEATER (S3i) � POR IRRIGA770N
_ WATER METER � OTHER
Nurnber of factures @ $IQ.Q�
Number offix�s Q $15.0�
xS100Q=�
x$Z5.00=�
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Number offixtures Qa $35.40 � x�3S.OQ = S►�_
State Surcimrge
$ S�
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TH[S IS AN APPLICATION FOR A PERMIT-110T VALtB UNfIL PROCESSED
i hereby appiy Fos a plumbing gertni# and I aolct►owiedge that the infor�nation above is compiete and acce�rate; ttaat the work will be in
cortformance with the ordinances and codes of the Ciry of Fridley and with the Minnesota Construction Codes; that L tmder�and this is
not a permit but only an application fior a permit and work is cwt to start withw�t a permit on sitc; that the work will be in acc�ordance
witl� the appraved plan in the of al ork whic ' es review and appro al of pians.
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S[GiVATURF.OFAPPLICANT PRINTNAME !tL}`" DATE / /°"r
: SEPARATE PERMITS ARE REQUIRED �QR
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City of Fridley �j��
Building I�spections Depar#ment ,���� � ���
6431 University Avenue NE; Fridley, MN 5�432
?d3-512-36U4
W119b�£Z�8 060Z/4Z/9 �a3�a L/L :a��d LZLZ Eb5 OZ£ :�oa�