P - 35346Building
Inspections
763-572-3604
763-502-4977 FAX
DATE J -'�
SITE ADDRESS _
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTTFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTfVE t-I-2011
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STATE LICENSE
STATE BOND # _
ADDRESS:
PHONE
�INGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
❑ REPLACEMENT
FAX
O TOWNHOUSE
Permit No� ���(,
Received By;.,,����1�
Dat�'�. J U L �
�STATF/�/([ZIP�
EXP DATE
EXP DATE
STATE ZIP.
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)
_ CLOTHES WASHER _ KITCHEN SINK WATER CLOSET �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
1 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 'on for a pen ' and work is not to start without a permit on site; that the wark will be in accordance
with the approved plan in the o all rk 'ch r quires review and appr 1 of plans.
SIGNATURE OF APPLICANT PRINT NAME (C�Hi�IR•.� "�`p �j,..�: DATE �% �� r�
APPROVAL INSPECTORS SIGNA E nn�r�
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977