P - 35325i
Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CIT� OF FRIDLEY
763-502-4977 FAX EFFECT[VE 1-t-2011
DATE � (
SITE ADDRESS
THIS APPI,ICANt' IS.
PROPERTY
UWNER/
TENANT
CONTRACTOR
SUBMIT A CdPY OF
Yovx sTA�
LICENSE, BOND AND
CERTII�ICATE OF
INSURANCE
PERMIT TYPE
❑ OWNER [�ION712ACTOR
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PHONE: ��„��$ ���,�
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STA1'B LICENSE # I�,�(Z��Dlnr-
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STATE BOI� #
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PHONE
TYPE OF WORK: I � �w
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DETAILED DESCRIPT'ION OF WORK
Permit No. 'W J 1�
Received By:
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,� �-� • c�r-,
STA'I � NLIP Z
EXP DATE 1
DATE �
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❑ TOWNHOUSE
FEES ARE BASED ON 510.00 PER FIXT[JRE, EXCEP'f WHQtE NOTED. EQ{TUItES: (INDICATE TOTAL NUMBER OF EACFI BELOVV}. MINIMUM EEE
535.50.
BATH SINK/L.AV FLdOR 17RAIN5 SHOWER WA1ER PIPING
BATHTUB GAS EIPING (NE� G17'Y LIC) G PfJOL WATER SOFTi*lIIt (S35)
CLC3TEIFS WASHER KITCHEN SINK ATER CLOSEC � BACKFLOW PREV. (S15j
_ bISHWASI3ER _ LAUNDRY TRAY ATER HEATER (�35) FOR 1RRIGATION
WATER 1N�TER OT}�E7t
rturnber of tii�ict�Ces (a� S35.o� x�s,tw ��
S�ie suecharge � 5.00
(MINIMUM S40»00) Tota1= $_ " � �
THIS IS AN APPLICATION FOR A PERhIIT NOT VALID UNTIL PROCESSID
I hereby apply for a plumbing permit and [ acknowledge that the information above is complete and accurate; that fhe work wil( be in
conformance with the ordinances and codes of the City of Fridley and with ttte Minnesota ConsUuction Codes; that I understand this is
not a permit but only an application for a pernvt 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 1 which requires review and approval of plans.
S[GNATURE OE APPL[CANT PRINT NA[v� DATE �/ �� f
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
753-572-3604
FAX: '763-502-4977