P - 39359Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �'J' �\ 1
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY N�
OWNER/ AL
TENANT
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PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
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❑ OWNER �,C91V'F ACTOR
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Permit No.:
Received By:
TAT9�I'V LIP.
CONTRACTOR NAME: �,y:�Ytr�c'S `'1Z_r'' ��tZ�1�-
SUBMIT A COPY OF STATE LICENSE # ��� ��' �T'Y� EXP DATE J I�=�� l� ,�
YOUR STATE
LICENSE, BOND AND STATE BOND # EXP DATE
CERTIFICATE OF pDDRESS: ��l '"' � �� � CI'1'Y r�,�Yi �ft'� STATEr1'►� ZIP 'SS�f�'
INSURANCE pHONE )t7r �l ��'''7� � FAX
PERMIT TYPE I GLE FAMILY
TYPE OF WORK: I� NEW
DETAILED DESCRII'TION OF
❑ TWO FAMILY ❑ TOWNHOUSE
PLACEMENT
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)
CL ES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
SHWASHER _ 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 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 case o�f work whic ' es review and approval of plans.
SIGNATURE OF APPLICANT G,./J1 ��� <'���" ��P R•IN�T AME �`C 5 j� G�'�� � DATE � ��� �
APPROVAL INSPECTORS SIGNATURE �yU y/ � DA
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 554�2
763-572-3604
FAX: 763-502-4977
PLEASE SEND PERMIT
TO HOME O�►�NER! !