P - 46955l3�o c�S
B�uiCding PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX
EFFECTIVE 2-19-09
DATE_� �R/��
SITL; AL�DRESS ____ SI
`CHIS APPL[C:ANT IS.
PROPERTY �
OWNER/
TENANT `
CONTRACTOR
SUBMI'T A COPY OF
YOURSTATE
LICENSE, BOND AND
CLRTIFICATI; OF
INSURANCl;
PERIVIIT TYPE
TYPE OF WORK:
DETAILE� DESCR(
_ �_ i .
.� Y UR E-MAIL ADDRESS
cr.�V'1'�'16[[�t Si� �
l
❑ OWNER �CONTRACTOR
PHONE: � /.� —
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J� � ` C/J� 7C.
NAME: [__�� �i/�Gl��f'�j `�
STATE LICENSE # �D Y �j %
STATCBOND# �ioZ'�J /��,
ADDRESS: 77D�, � �
PHONF, q� oZ —' -( � i`� D
I�SINGLE FAMILY
/
❑ NEW
[ON OF W ORK
❑ TWO FAIViILY
J�REPLACEMENT
� �
ac� u�� Tc�d
CITY
FAX
t
❑ TOWNHOUSE
Permit No:
Received By? � ��
D�c'd:� � � �
ATE �%I�"L1PJ�S�f.��
EXP DATE
�XP DATE
!�R"r�'Q' STATE�''�ZIP,�ti�
— ��f1- 1q67
1
FEES ARG BAS�D 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 P[PING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
_ CLOTFiES WAStIF,R _ KITCHEN S1NK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LALINDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
Number of tixtures @ $10.00
Nuanber of fixtures @ $15.00
Number of fixtures @ $35.00 �
x $10.00 = $
x$15.00=$ �
�"�. .
x$35.00=$ � ��
State Surcharge $ .50 '��
� � �-� ��
MINIMUIVI $35.50 Tota1= $ ��+
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID 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 codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a pern�it but only an p ation for a and work is not to start without a permit on site; that the work will be in accordance
with the approved plan 'n th ca e of a wor ich requires review and appr al of pl s.
SIGNATURE OF APPLICA , PRINT NAME f�''` �U' ��5�"1 DATE ( 4 r_C I(
PLEASE NOTE: SEPARATE PE ITS ARE REQUIRED FOR BUILDING, ELECTRICAL AND MECHANICAL WORK
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977