P - 46721Building
Inspections
763-572-3604
763-502-4977 FAX
DATE 1 1I
SITE ADDRESS
THIS APPLICANT 1S:
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
PLUMBING
RESIDENTIA.L APPLICATION
CITY OF FRIDLEY
EFFECTIVE i-1-2011
YOUR E-MA1L ADDRESS
❑ OWNER
ADDRESS: V 5�
7
PHONE:��
NAME: (
STATE LICENSE #_
STATE BONJ���
7
ADDRESS: �
PHONE -=�1=�—
�SINGLE FAMILY
TYrE oF woxx: I� NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
`gl REPLACEMENT
r�
CITY�
FAX
❑ TOWNHOUSE
Permit No.: � � (
., _,.
' - -� : J; l�'.
�. ' -� � II'
.�
.r i�� : � � ��
ATFIV(N, ZIP
EXP DATE
EXP DATE
i STATE ZII�,�F�-
FEES ARE BASED ON $] 0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATERCLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LINTIL 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 o City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applic tion f a pe it d work is not to start without a permit on site; that the work will be in accord ce
with the approved plan in th c of o ch requires review and approv�/� �ans. `"���
SIGNATURE OF APPLICANT PRINT NAME fn// �7/*�' DATE
APPROVAL INSPECTORS SIGNATURE ______ DATE
(/ � City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977