B - 45475Building
Inspections
763-572-3604
763-502-4977 FAX
DATE % -//�!
SITE ADDRESS
--�
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
NAME: �y,�>��
aDD�ss:�
PHONE: G ��/
NAME:
STATE LICENSE #_
STATE BOND #
ADDRESSOI��
PHONE ��. .�.b��
C�3'SINGLE FAMILY
❑ NEW
DBTAILED DESCRIPTION OF WORK
YOUR E-MAIL ADDRESS
O TWO FAMILY
�REPLACEMENT
Permit No.: `v'� � � L���
Received By�� �
D�it�c'� E�
CITY
EXP DATE
EXP DATE
2
_ FAX
❑ TOWNHOUSE
ATE ZIP
ATE
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 PIPING (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 PERM7T-NOT VALID UNTIL PROCESSED
WATER PIPING
� WATER SOFTNER ($35)
BACKFLOW PREV. ($IS)
FOR [RRIGATION
,�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 City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application ermi n is not to start without a rmit on s� e• that the work will be in accordance
with the approved plan in the case or s review and ap ro � ns`�/ G��''
SIGNATURE OF APPLICANT PRINT NAME � DAT� ��/ //
APPROVAL INSPECTORS SIGNA RE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977