P - 35457Bu11di11g PL�JMBING permit No.:2�1(�(j� `� �
Inspections RES�D�+ NTIAL t�PP�,IC��'I4N Received By:
763-572-3604 ��TY OF �'RIDLEX D '� � � � � �� �
763-502-4977 FAX ���
EFFECTIVE 1-1-2011
DATE .�/1 b I L1
—.-�-T—
SITE ADDRESS _
THIS APPLICANT 1S:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
YOUR E-MAIL ADDRESS
l.i h ��
❑ OWNER O
NAME: �.N�
ADDRESS: �!
PHONE:� �_�Ir —
NAME: i
STATE LICENSE #
STATE BOND #
ADDRESS: 2 �O P u �i
PHONE ��^9°�N'� i
PERMIT TYPE �S�GLE FAMILY
/ �
TYPE OF WORK: I� NEW
DETAILED DESCRIPTION OF WORK
CITY
❑ TWO FAMILY
�'�EPLACEMENT
�\,
❑ TOWNHOUSE
EXP DATE
EXP DATE
� STATE ZIP S �?
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV�. MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
_ CLOTHES WASHER KTTCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
DISHWASHER _ LAUNDRY TRAY �WATER 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 I acknowledge that the information above is complete and accurate; that the wark 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 � ark is not to start without a permit on site; that the work will be in accordance
with the approved plan in t ase f al orl w�ch quires review and approv 1 of lans. /y
SIGNATURE OF APPLICANT h� � � PRINT NAME �I G� ���-�f� DATE �F, u I
APPROVAL INSPECTORS SIGNATURE _ ____ DATE `'
City of Fridley
Building Inspections Department
6431 University Avenue NE; Fridley, MN 55432
763-572-3604
FAX: 763-502-4977