P - 41204Building
Inspections
763-572-3604
763-502-49,77 FAX
DATE \ / /:
SITE ADD�`
TENANT
PROPERTY
OWNER/
TENANT
PLUMBING
COMMERCIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-20] l.
NAME:
ADDRESS.
PHONE:
YOUR E-MAIL ADDRESS
SU[TE NO,
Permit No.
Received By: / \ �
�.. �
Date Rec'd:"' �f °, `"
ATE ZIP
CONTRACTOR NAME: � � `�' %�S
SUBMIT A COPY OF STATE LICENSE # � L' � C' EXP DATE
YOURSTATE
LICENSE, BOND AND PLUMBING BOND # EXP DATE
CERTIFICATE OF ADDRESS: ��� I�`�"" �:��T�,��. CTTY CO j„ • Q�'� STAT� IP .�? J LJ�:
INSURANCE .� r—. '
PHONE"(� ( c-'�- 1 l° ZS � J'� FAX
PERMIT TYPE
TYPE OF WORK:
❑ INSTINTIONAL
❑ TOWNHOUSE
� NEW
�ULTI-FAMILY
COMMERCIAL/[NDUSTRIAL
�EPLACEMENT
Cl SWIMMING POOL
CI OTHER
O ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �?�15 `�""��`��-w /{c? �.� f�� '��' � c�j O�
�7Q ( 1�� �� - � �—
_ CLOTHES WASHER
_ DISHWASHER
_ DRINKING FOUNTAIN
_ FAUCET
_ FLAMMABLE WASTE TANK
Total Job
Valuation
Permit Fee
Surcharge
Total Due
;H)
UFLOOR DRAINS RPZ VALVE URINAL
?�i'iAS PlPING BACKFLOW PREV. , WATER HEATER
_ GREASE TRAP _ ROOF DRAINS WATER METER
_ KTTCHEN SINK _ SHOWER WATER PIPING
_ LAUNDRY TRAY _ SLOP SINK WATER SOFTENER
_ LAVATORY _ SWIMMiNG POOL WATER CLOSE7
$���.�..: , �,
All fees are based on valuation, including the cost of ]abor and materials. 3�
$� �1.25% of Job Valuation / Minimum fee: $35)
$ _ ��� Valuation X .0005 or Minimum .50
$ t�4��= Make Checks Payable to: City of Fridley
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 comptete 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 t all wark �ch requires r iew and approval of plans.
SIGNATURE OF APPLICAN : P T NAM . �� r�� �—� I��TE: \ /
APPROVAL INSPECTOR SIGNATURE: � DATE� �! �I
City of Ffidley Building Inspections Department
6431 University Avenue NE, Fridley, NIN 55432
763-572-3604 FAX: 763-502-4977