P - 48298Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � -a-1
SITE ADDRESS _
T'HIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
IldSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECT'IVE 1-1-2012
E-MAIL ADDRESS
❑ OWNER �ONTRACTOR
ADDRESS:
PHONE:
Permit No.: 2o I,oZ'�b �`t"`�
Received By:�_
Date Rec'd: 2� � 4�
ATE ZIP.
NAME: t W e�. ¢�/ l�V v`+C-
STATE LICENSE #(p� e��S - i'�i EXP DATE 1��3 i-� 01�-
STATE BOND # EXP DATE � "'� ) � �� 3 _
ADDRESS: S"`D�Lo �10ks. �- CITY �'� s STATE/`��✓ZIP S`s 3 y%
PHONE % Io 3� e� ��� �('t� � FAX 6�3 - 3S°j - SS CS �
I�$INGLE FAMILY
t
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
�1tEPLACEMENT
!
❑ TOWNHOUSE
�
FEES ARE BASED ON $10.00 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)
CLOTf�S 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 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 applic io for ermit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the c e a wo k�+ahich requires review and approv�f,plan� �
SIGNATURE OF APPLICANT PRINT NAME v s L� �E �� DATE �' o� '� o�`—
APPROVALINSPECTORSSIG A E _ DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977