P - 36681Building
Inspections
763-572-3604
___ _ _
��763-502-4977 F.
DATE .`�
SITE ADDRESS I
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
�
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-I-2010
YOUR E-MAIL ADDRESS
❑ OWNER �1CONTRACTOR
ADDRESS: CI"fY
PHONE:
STATE LICENSE #
STATE BOND �
ADDRESS:
PHONE I'^
�SINGLE FAMILY
�NEW
i .50 �=-
❑ TWO FAMILY
❑ REPLACEMENT
FAX '—
❑ TOWNHOUSE
PermitNo.�(3�4�0�� �
Received By: ��t
Dat��dNaU 1 � 2�
TE ZIP
EXP DATE
EXP DATE
v +ti-� STATE��ZiPy���
DETAILED ESCRrIPTION OF WORK ���Sa� � rav w� i � LS�iSr v+,:�w� �' ��S'%a � I �U.� w/
i/'�°i�t� � ��f ��
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BEIAW). MINIMUM FEE
�$3 .50.
BATH SINK/LAV FLOOR DRAINS Ii SHOWER WATER PIPING
_BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL � WATER SOFTNER (S35)
CLOTHES WASHER KITCHEN SINK � WATER CLOSET � BACKFLOW PREV. (S15}
_ DISHWASHER _ LAUNDRY TRAY ,.,�WATER HEAT�ER (S35) � 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 aclrnowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit br�t only an application fo a ermit d work is not to start without a permit on srte,•�hat the work wil] be in accordance
with the approved plan in c e ork ich requires review and approya f pl /,J�/-.
- �'°�'LICANT PR1NT NAME �``�������' b v- DATE l� l' lc)
�� �
APPROVAL INSPECTORS SI
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977