P - 35797Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ` I � t � I
S[TE ADDRESS �� 3
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
W
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
���
❑ OWNER
STATE LICENSE #
YOUR E-MAIL ADDRESS
uh
Permit No
Received By:
EXP DATE
ATE
STATEBOND#_��}'1'1,�1I�(l'��ee9 ����'� `�`'`�' `� EXPDATE
ADDRESS: Q������J-��:7� CITY STATE ZIP.
PHONE
FAX
SINGLE FAM[LY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: O NEW �REPLACEMENT
DETAILED DESCRIPTION OF WORK a
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 WATER PIPING
BATHTUB GAS PIPING (NEED C[TY LIC) SWIMMING POOL � WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
DISHWASHER LAUNDRY TRAY _WATER HEATER ($35) FOR IRRIGATION
— WATER METER _ OTHER
THIS IS AN APPL[CATION FOR A PERMIT-NOT VAL1D UNTIL PROCESSED
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 odes o the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application or pb it and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in th 1 r uires review and approv I of p ans. ,�y �_ I���(
SIGNATURE OF APPLICANT PRINT NAME�c (� �YI� Ce � L%F7�-T � DATE t
APPROVAL INSPECTORS SIGN RE _ ___ _ .
(�' City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977