P - 35459Building
Inspections
763-572-3604
763-502-4977 FAX
DATE_LI � I.
SITE ADDRESS �
THIS APPLICANT IS
PROPERTY
OWNER!
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
PLUMBING Permit No.:�I I ��"�
RESIDENTIAL APPLICATION Received By: ��_
CITY OF FRIDLEY r���I�� "
EFFECTIVE 1-1-2Q11
R E-MAIL ADDRESS
❑ OVVNER ❑CONTRACTOR
PHONE: (,P � Z ZZ('� 7I �FD
NAME: 1�1�J(/( l'
STATE LICENSE #_
S'fATE BOND # _
ADDRESS:��
PHONE `I�,Q%i "
TYPE OF WORK: I� NEW
FAMILY ❑ TWO FAMILY
❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK
EXP DATE
EXP DATE
_CITY
_ FAX � 3- 78�
❑ TOWNHOUSE
. • L�X'1aFfit� Lio��,
ATE ZIP.
STAT�ZIP S�
-bb a-(
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 C[TY LIC) _ S WTMMING POOL WATER SOFTNER ($35)
_ CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY ��yVATER HEATER ($35) FOR fRRIGATION
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 ' ormation above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridl a with the Minnesota Construction Codes; that I understand this is
not a permit but oniy an application for a permit a ork is t t start without a permit on site; that the work will be in accordance
with the approved plan in t �s of a(I work wl�ich r ie and approv� lans. :r��
SIGNATURE OF APPLICANT ` P NT N I i.i� �� Zt. DATE 3 1 S r 1
APPROVAL INSPECTORS SIGNAT _ �/� �� DATE '� i
C�i y' of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977