P - 48218Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ��^o� l� i
SITE ADDRESS 5 S I�
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBNIIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
❑ OWNER
ADDRESS:
Permit No.:
ReceivedrBy: � ,
Date i�eL'l�: �
YOUR&MAILADDRESS_��(U�'Ti��IP✓i'�/bLNJ✓�C�ikCYLI�(n►m��.�i�� n��
rlC� I�Gt� _
�ONTRACTOR
� �-a � _
CI1'Y
STATE LICENSE # � EXP DATE %a � 3/ � l'•
STATE BOND # �n 1 LcL EXP DATE
ADDRESS: �D� � � r1 CITY /�Yl 01�0. STpAT��'1 ZIPS 3
PHONE �� 3��� o� ���d FAX v`�G3 -'S`?a. ` a$��
❑ SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY �TOWNHOUSE
�B,FPLACEMENT
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER
BATHTUB GAS PII'ING (NEED CITY LIC) SWIMMING POOL
CLOTHES WASHER KITCHEN SINK WATER CLOSET
_ DISHWASHER , _ LAUNDRY TRAY _WATER HEATER ($35)
WATER METER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
WATER PIPING
WATER SOFTNER ($35)
BACKFLOW PREV. ($IS)
FOR IRRIGATION
OTf�R
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 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 the se of rk which requires review and ap1�� val of plan�. . - _ j Z-- '�Z7— /� �
SIGNATURE OF APPLICANT ��� PRINT NAMEt_G� � Y� t` ��� S � M V�^ u i�sDATE
APPROVAL INSPECTORS SIGNATURE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
1�