P - 35826Building
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
EFFECTTVE 1-1-2011
°y�pWNER
NAME:��)
ADDRESS:� fi�
PHONE:],�3—
NAME:
STATE LICENSE #_
STATE BOND # _
ADDRESS:
PHONE
GLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑CONTRACTOR
❑ TWO FAMILY
❑ REPLACEMENT
CITY
FAX
0 TOWNHOUSE
Permit No.:Z'�' 1�'�� ��}"
Received By.
D�E�"'�'��.1'; � 5 c�
EXP DATE
EXP DATE
ATE ZIP_
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
BATf�ITUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
_ CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL1D UNTIL PROCESSED
I�by 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 for a permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in t e c s ark which requires review and appr va of plans. �y ^ �
SIGNATURE OF APPLICANT � �, PRINT NAME ��-/� DATE 25��
APPROVALINSPECTORSSIGNA tI . � nn�rc—
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977