P - 42768Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � ` � � � l �
SITE ADDRESS ��� •! 7 '
TENANT
PROPERTY NAME:
OWNER/ ADDRES
TENANT
PLUMBING
COMMERCIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011.
�j� `Y/OUR E-MAIL ADDRESS _ h�� �u � _
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0
CONTRACTOR NAME: LLQS�
SUBMIT A COPY OF STATE LICENSE #
YOURSTATE -
LICENSE, BOND AND PLUMBING BOND #
CERTIFICATE OF ADDRESS:
TNSURANCE !� ;��y
PERMIT TYPE � INSTiTUTtorra[.
❑ TOWNHOUSE
TYPE OF WORK: � NEw
�
�ESCRIPT�IQ OF WORK ''
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SUITE NO.
CITY �`� �-✓�
i �Yl.i- �%t� �
CITY
FAX
IYIGIULTI-FAMILY
❑ COMMERC[AL/TNDUSTRIAL
❑ REPLACEMENT
Permit No.: �' s�1/ f
Received By: �/�, "
`L��� r
_ EXP DATE
�EXP DATE
J e�
°3�3 -- ��;
, �t�, - �.
_STATE�ZIP_
�a�31- i �
STATE ZIP_J'f
9 L �':-�� rmn ._�
❑ SWIMMING POOL
_. _, ._._._ _ CC OTHER
C] ALTERATION/REMODEL
�£�TURES: (INb7�A,'T`�.I'�7T�i. NL`J3v1$�It. bF EACi�)
_ CLOTHES WASHER _ FLOOR DRAINS _ RPZ VALVE URINAL
_ DISHWASHER _ GAS PIPING BACKFLOW PREV. WATER HEATER
_ DRINKING FOUNTAIN GREASE TRAP ROOF DRAINS WATER METER
_ FAUCET f KiTCHEN SINK �SHOWER _ WATER PIPING
_ FLAMMABLE WASTE TANK LAUNDRY TRAY _ SLOP SINK WATER SOFTENER
� LAVATORY _ SW[MMING POOL WATER CLOSET
Total Job
Valuation
All fees are based on valuation, including the cost of labor and materials.
Permit Fee $ 1� (1.25% of Job Vafuation / Minimum fee: $35)
Surcharge $�� Valuation X.0005 or Minimum .50
Total Due $-1 u-�`! Make Checks Payable to: City of Fridley
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 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 permi� on site; that the work will be in accordance
with the approved plan in the ca of ll w k hich requires review and approval f plans.
SIGNATURE OF APPLICANT : PRINT NAM Y l �` K�S DATE: - J^
,;
APPROVAL INSPECTOR SIGNATURE: ° .. � ��� DATEJ < I�'���
City of Fr�dley Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977