P - 35062Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ��` �'l -
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
YOUR E-MAIL ADDRESS
❑ OWNER
ADDRESS: C1TY
STATE LICENSE
Permit No.:��� �O
Received By: j ! �
�-
Dat�d•
ATE ZIP
EXP DATE � �'J � '
STATE BOND # 3�,Q �%N�ZF> EXP DATE �� �'
ADDRESS: � g% Z����ji.�i f�� � CITY �j��./ jL/ ,P STAT�ZIP�
PHONE 7�.?%y7S� :� — [S J `7 .� FAX � 6 � "'7� 7— � �,5�
�SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � �W � �pLACEMENT .
DETAILED DESCRIPTION OF WORK �
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELAW). 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 WATER CLOSET BACKFLOW PREV. ($15}
_ DLSHWASHER _ LAUNDRY TRAY [�'fER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
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 permit on site; that the work will be in accordance
with the approved plan in the� cas�ef� 11 work which requires review and approval of pl sp. j /'
SIGNATURE OF APPLICANT�a'Pw.v�,��J�.�. � �r�% PRINT NAME��r � Iri � . �i1�%/ DATE � / � �'I' °- J �
APPROVAL INSPECTORS SI NATURE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977