P - 48278Building
Inspections
763-572-3604
763-502-4977 FAX
DATE
srrE nDDxESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE i-1-2012
� �
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� �����L\�)e�R'��.'
COI�ITRACI`UR
SUBMTI' A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFTCATE OF
n�rsu�cE
PERMIT TYPE
TYPE OF WORK:
PHONE:
STATE LICEf1SE #_
STATE BOND #
ADDRESS:��
PHONE 71�3 _
�SINGLE FAI�rIILY
❑ r�w
DETAILED DESCRIPTION OF WORK
YOUR E-MAIL ADDRESS
1Ci eC'� Ve /U. cc .
❑ TWO FAMII.Y
�l xEri.nCE�T
/�
P�t No..
Received By;
Da�`��'� �
� S�" 3
EXP DATE
EI� DATE
� [�sse c� �A�rnN �.ss3 6
F.� ��3 - �-as- 7 � I
� TOWNHOUSE
FEES ARE BASED ON S 10.00 PER FIXTURE, EXCEpT WHERE NOTID. FIXTtJRES: (IlVDICATE TOTAL NUMBER OF EACH BELOR�� N�IIMMUM FEE
535.50.
_ BATH SINKILAV FI.00R DRAWS SHOWER WATER PIPING
_ BATHTUB GAS PIPING (NEED CITY LIC) SWINA�IIIVG POOL WATER SOFfNER (S35)
CLOTEIES WASHER _ KITCHEN SINK WATER CLOSEI' BACKFI.OW PREV. (S15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER (S3� FOR IRRIGATION
_ WATER METER � p�
Number of � Qa �10.00
Number of fixt�u�es @ �15.00
xS10.(�=$
xS15.0(l=�
Number of fn�ctures @ �35.00 � x �35.Q0 = � ,�j✓r' . �
State S�mcharge
$ S.OQ
Tota1= S �"r% ,U25
THIS IS AN APPLICATION FOR A PERMIT�JOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I aclrnowledge tl�at the infotmation above is c;o�nplete and aecurate; that the work will be in
conformance wiffi the ordinances and City of Fridley and with the Minne�a Construction Codes; that I understand this is
not a permit but only an application far a permit is not to start without a pe�mit on site; that the work will be in accordance
wi� �e approved plan in the of all w 'ch 'ew and approvai of plans. �f
SIGNATURE OF APPLICANI' P NAME ���:{ DATE I c� �°�
APPROVAL IAiSPEC!'ORS SIGN BAT'E
PLEASE NOTE: SEPARATE P UIRED F R BUIl.DING, ELECTRICAL AND MECH C: i. nRK
eity of Fridley
(-B'uilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977