P - 45205Building
Inspections
763-Si2-3604
763-502-4977 FAX
DATE ! " (J "- 1 l
SITE ADDRESS I
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER �3(CONTRACTOR
ADDRESS: ll.��} Z�l .,frj� �� /�V�-
PHONE: �(-;.�j S�:"c`�- (�:3 � � �
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Permit No.:
Received By:
Date Rec'd:
STA'
STATE LICENSE # v C��'� ;j t} ��j � jVj � EXP DATE I Z' C �' ��
STATE BOND # `7 � ! ��;j '� EXP bATE r � � 3 i - � �
ADDRESS:��O �I U! ✓ai •.� •�� .A�1C -�a CITY 5"F' - I-c,i*.y ray� STATE�� ZIP S�J
PHONE �% S� Z°i Z- ,'3 ;:3`:�U FAX
.
`�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
�
G �
�
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
BATHTUB ~ GAS PIPING (NEED CITY LIC) SWIMMING POOL
CLOTHES WASHER KITCHEN SINK WATER CLOSET
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35)
WATER METER
WATER PIPING
WATER SOFTNER ($35)
BACKFLOW PREV. ($15)
FOR IRRIGATION
_ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing pe 't a I ac wledge that the information above is complete and accurate; that the work will be in
conformance with the ordi es code of t City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an a pli at' or is no o start without a permit on site; that the work will be in accordance
with the approved plan i e e i equire�iiova a d approval of plans.
SIGNATURE OF APPLICANT AME DATE
APPROVAL INSPECTORS SIGNATURE i�1i1 DAT ,
._..� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
+`�'� l ��