P - 48051Building
Inspections
763-572-3604
763-502-4977 FAX
DATE J G
SITE ADDRESS _�
7'HIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTTVE 1-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER �ONTRACTOR
NAME:
ADDRESS: CITY
PHONE: � � � ' ys7 — S� 4 �/
NAME: ✓v� iv�-�� ¢-�'
Permit No.: >�� � �'��
��'�e���� �
a e ec
STATE ZIP
STATE LICENSE if�'`� �_j S"' P h^ EXP DATE � Z"— 3 �—' I 2
STATE BOND # EX(P� DATE
ADDRESS: 1��� 13C.E'(��^ C��dz..� �f'� CITY ^ c-"'�if�i�V'i� STATE�h%-rZIP S���l'
PHONE �.� Z "�'LC�S "ZO � I FAX
TYPE OF WORK: I� NEw
FAMILY
TAILED DESCRIPTION OF WORK _ 1�(
..T `��c�fc__ : "��-�-. �--�=�:
❑ TWO FAMILY
*�REPLACEMENT
❑ TOWNHOUSE
� � k �-�-�+-�5 "� V�s
�. l\ .
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (]NDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
3 BATH SINK/LAV FLOOR DRAINS SHOWER
� BATHNB GAS PIPING (NEED C[TY LIC) SWIMMING POOL
CLOTHES WASHER l KITCHEN SINK � WATER CLOSET
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35)
WA7'ER METER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
WATER PIPING
WATER SOFTNER ($35)
BACKFLOW PREV. ($15)
FOR IR.RIGATION
_ OTHER
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 ity of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applicatio for a ermi d work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the cas Il �c ._ ' s v ew and approva �p ans. �'�'`�
SIGNATURE OF APPLICANT ' PRIN^T�� M,,E �!� ���DATE 3 % I _
APPROVAL INSPECTORS SI ATUR C% L�C/ / DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridiey, MN 55432
763-572-3604
FAX: 763-502-4977