P - 35330�uilding P��..LTI���l��
�nspections ��SID�I��'IA�. A��LI���'�OI�
763-572-3604 ���� �� �������
763-502-4977 FAX EFFECTTVE i-i-zo�o
DA-� - v -
SITE ADDRESS
THIS APPLICANT IS:
PI20PERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
� V YOUR E-MAIL ADDRESS
�Psr�ll,v� ��' ��.-=��
❑ OWNER CONTR.ACTOR
NAME:
ADDRESS: _ CITY
�����
Permit No.:
Received By: 1 1 l!'
Date��! 4 yf�.. i 1
� ``°"' �
ATE ZIP
STATE LICENSE # 'r "' �� v-r�v� EXP DATE
STATE BOND # 4R��1 fl,,.a.a o.a EXP DATE
ADD�ss: Eaaan,� �5y 23 CITZ' STATE ZIP.
PHONE FAX
�INGLE FAMILY
❑ NEW
DETAILED DESCRII'TION OF WORK �
❑ TWO FAMILY ❑ TOWNHOUSE
[�2EPLACEMENT
/-.
FEES ARE BASED ON $]0.00 PER FIXNRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV _FLOOR DRAINS _ SHOWER _ WATER PIPING
—gp��g GAS PIPING (NEED CITY LIC) SWIMMING POOL _ WATER SOFTTIER ($35)
CLOTHES WASHER � KITCHEN SINK WATER CLOSET _ BACKFLOW PREV. ($15)
DTSHWASHER LAUNDRY TRAY WATER HEATER ($35) n FOR IRRIGAT'ION
— — _ WATER METER OC. OTHERI
!� ,v 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 pertnit but only an application for a perrrtit 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 of a work 'ch r uires review and appro al of plans.
SIGNANRE OF APPLICANT p ��"'" ""���PRINT NAME DATE ! v� V�
:� :��s�<„°.
City of Fridley
Building Iaspections Departrnent
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
' FAX: 763-502-4977
.
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