P - 36786Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�- I o2 ` %
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-i-2011
YOUR E-MA[L ADDRESS
❑ OWNER �CONTRACTOR
NAME:
ADDRESS:
PHONE:
STATE LICENSE
Permit Na!
�-- -.: �,
;:� _ , ` � r�al
TE ZIP.
EXP DATE _ �a'31' / Z
STATE BOND # EXP DATE
ADDRESS: IG'2600 c�'p'� S1'� CITY BId,►V�¢- STATE�III/ ZIP S 3
PHONE 7�o3-�a�-R�a4 FAX
�l SINGLE FAMILY
❑ NEW
O TWO FAMILY ❑ TOWNHOUSE
1� REPLACEMENT
DETAILED DESCRIPTION OF WORK �szPLac� `�v-u.s�,-�— g� d� u., }-a.r �/ 1��
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 LtC) 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
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 tlri�as�l�jw�r wh'ch requires review and appr�l of�an��✓a�1�
SIGNATl3REOFAPPLICANT I.0 )'" PRINTNAME �,6�U� DnTE 8-1a-//
APPROVAL INSPECTORS SIGNATIJRF, ne-rc
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977