P - 35798Building
Inspections
763-572-3604
763-502-4977 FAX
DATE -- �`� � ��
SITE ADDRESS �
--�.
THIS APPLICANT [S
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
NAME:
PLUMBING Permit No.:2.O o�I
RESIDENTIAL APPLICATION Received By.
CITY OF FRIDLEY va�e"�d��Y�< ��o j
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
❑ O�NER �ONTRACTOR
��
CITY
PHONE: �
NAME: _�S �G�1lD.0 �° �G�•< � - ( C� C
STA'CE LICENSE �_f%5 y'S/ 7 Q'""fY ✓
STATE BOND # �� 7 S� S�
ADDRESS: �� CITY �
PHONE ��o �" I PD��� FAX
�INGLE FAMILY D TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � o NEw
DETAILED DESCRIPTION OF WORK
�REPLACEMENT
A
EXP DATE �o� `- o��% �
EX,P., (D'ATE % � �f
�/ / STATEG�_ZIP
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$3 .50.
�Z� BATH SINK/LAV FLOOR DRAINS � SHOWER WATER P(PING
� BATHTUB GAS PIPING (NEED CITY LIC) S WIMMING POOL � WATER SOFTNER ($35)
_ CLOTHES WASHER KITCHEN SINK � WATER CLOSET � BACKFLOW PREV. ($15)
_ DISHWASH�R _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby app(y 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 appl' 'on for a per 't and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in th of al wor l�ich r q' s review and appr 1 of plans./' / ` //
SIGNATURE OF APPLICANT rG� PRINT NAME��i� I� (rj/ /�/D/ � DATE �'� /�//
APPROVALINSPECTORSSIGNATURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977