P - 35447Building
Inspections
763-572-3604
763-502-4977 FAX
ri_�
SITE ADDRESS _
THTS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMTI' A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-20] 1
YOUR E-MAIL ADDRESS
❑ OWNER �ON7RACTOR
• . • Z:� �I.1'�iT:J�fITii!�l.�
• ��• '�.�
. � , �
Permit No.:20���
Received By;
f�[��'19�
TE ZIP
STATE LICENSE # � � EXP DATE
STATE BOND # ^ EXP DATE
ADDRESS: OC�� �Q.1� n s� n�*3Q� �1i��1 STATE ZIP
PHONE %EO � ZS�{"e�.L4 � FAX
• �ERMIT TYPE •� S�GLE FAMILY
TYPE OF WORK: � NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
�'I2EPLACEMENT
W
FEES ARE BASED ON $]0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXNRES: (INDICATE TOTAL NUMBER OF EACH BELOW): MINIMUM FEE
$35.50.
BATH SINK/LAV FLOORbRAINS SHOWER WATERPIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMbIING POOL WATER SOFTNER ($35)
CLOTF�S WASHER KITCHEN SINK WATERCLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �VATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and T 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 appiicatio fo a permit and wark is not to start without a permit on site; that the work will be in accordance
with the.approved plan in the cas orl h re u' • s review and appro f plans.,
SIGNATURE OF APPLICANT PRINT NAME��r ���CI�D DATE � �
APPROVAL INSPECTORS SIGNA � . �-DATE_ _ ` �
� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN� 55432
763-572-3604
FAX: 763-502-4977