P - 60320Building
Inspections
763-572-3604
763-502-4977 FAX
DATE_ `� -' , I �
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2012
SITE ADDRESS �(�,,�'i 7 C?(d : i' �
THIS APPLICANT IS: ❑ OWNER
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
NAME: _ _�
Permit No.: ' �1 ���;��
Received By� ' V
Date Rec' d: _ � � � �. +
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YOUR E-MAIL ADDRESS ,%!!Z rv� �f�-�y�► V ,� � �,�,Q /`�L/�'i %2G
�'d� /� � . �— �—
T�l •�ZIP
PHONE: l /. � � �I 5 ' °Z � � �
STATE LICENSE #� � % ��N^� ✓ � EXP DATE ,/�iZ - � �� / �
STATE BOND # 1�(�,�q 7,��Ofi_�� EXP DATE � z° 2u f�/�
�nxESS:�ILI� �••.� �30 ��i sS�v.c �v� c��r5r���.c�j, � STATE�ZIP�j�.
PHONE '�J,% '�l ° �%— D �� %`� FAX
PERMIT TYPE I�S�GLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: I � �"'' ��PLACEMENT
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DETAILED DE CRIPTION OF WORK �/•�i�J l,r1GG �.`G � S� ^� �,5�'a�� Y� ✓1 Di ✓�!
✓1 .s-�----� �!� .—
FEES ARE BASED ON $10.00 PER FIXNRE, EXCEPT WHERE NOTED. F ES: (INDICATE TOTAL NUMBER OF EACH BELQW). MINIMUM FEE
$35.50.
� BATH SINK/LAV I FLOOR DRAINS I SHOWER _ WATER PIPING
BATHTCTB GAS PIPING (NEED CITY LIC) SWIMMING POOL _ WATER SOFTNER ($35)
CLOTf�S WASHER KITCHEN SiNK � WATER CLOSET _ BACKFLOW PREV. ($15)
_ DISHWASHER � LAUNDRY TRAY _WATER HEATER ($35) FOR IRRIGATION
W ATER METER _ OTE�R
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 permit but only an application for a ' n ork is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case of wh' ires review and approval of plans. �1
SIGNATURE OF APPLICANT PRINT NAME �,���_� w('� DATE� �/�
APPROVAL INSPECTORS SIGNA
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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