P - 46482Builuing
I*�spections
763-572-3604
763-502-4977 FAX
DATE � 1 "� ' -i
SITE ADDRESS<�.5
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
�
� ��� 1 � ���� l.�
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
❑ OWNER
YOUR E-MAIL ADDRESS _
,�. 'F-�r� C L�SL�-,
Permit No.:
Received By:
�
ADDRESS:�� -,� �"� I �/j"1C`y'C ��� if1.!r= CITY�1/"1C��.4.�'i STATE�I�IP.�}r.'3,%
PHONE: ��.,p„�— `'.��' �'�J`� �
NAME:
STATE LICENSE #, ��t c�C1 C� �"'� �ii'y'1 EXP DATE ��''" 3' l�-
STATE BOND # EXP DATE
ADDRESS: ��"! � S L,�,�.Q CL�� �CITY �~( Gt.`�1 �L'�-ti�31 STAT�11� ZIP
PHONE �� . �cy.'S7 L �-'� � �Lo�'-� � FAX
TYPE OF WORK: I� NEW
FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
PLACEMENT
DETAILED DESCRIPTION OF WORK �
C�.L�. C \ �� �
� —
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 CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
1 DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowledge at the information above is complete and accurate; that the work will be in
conformance with the ordinances and. codes of the Ci of idley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a pe ' n work �s not to start without a permit on site; that the work will be in accordance
with the approved plan in the case of all ich uir s review and appr�;v of pl ns.�- u\` �%
SIGNANRE OF APPLICANT NAME ( � ' �,, ����ATE � L � �
APPROVAL INSPECTORS SIGNANRE
r City of Fridley
Buil ing Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
PLEASE SEND PERMIT
TO HOME OWNER!!