P - 35451Building
Inspections
763-572-3604
763-502-4977 FAX
DATE
SITE ADDRESS _
TH[S APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIF[CATE OF
INSURANCE
PERMIT TYPE
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
YOUR E-MAIL ADDRESS
�
CITY
Permit No.: �
. . - - . : .7<<:
� , �, , � � ! � I II
,�:, .
NAME:
STATELICENSE ,� iance Connections inc EXPDATE
STATE BOND # '� '; �"' �� i� C'�,r• EXP DATE
ADDRESS: C��L.�.�.�.., �d��l_�e2��j1'—
. .-r
PHONE � FAX
TYPE OF WORK: I� NEW
FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
DETAILED DESCRIPTION OF WORK
�LREPLACEMENT
r
A'
STATE ZIP
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: ([NDICATE TOTAL NUMBER OF EACH BELOW}. MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHNB GAS PIPING (NEED CITY L[C) ^ SWIMMING POOL ^ WATER SOFTNER ($35)
CLOTHES WASHER i KITCHEN SINK ^ WATER CLOSET `BACKFLOW PREV. ($IS)
DISHWASHER LAUNDRY TRAY =WATER HEATER ($35) � FOR IRR(GATION
— 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 appli tion 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 th ` w r� ' quires review and approval of pl� �� ,%���� r�`� �!/
SIGNATURE OF APPLICANT PRINT NAME �/� �✓I r DATE vJ
APPROVAL INSPECTORS S1GNA URE _
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977