P - 41802Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �/� � �
SITE ADDRESS '�
THIS APPL[CANT IS:
PROPERTY N�
OWNER/ AL
TENANT
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
krr►wnn � j �
❑ OWNER �CONTRACTOR
- Zob ,S�D�IU
CONTRACTOR NAME:��%
SUBMIT A COPY OF
YOUR STATE STATE LICENSE #
LICENSE, BOND AND STATE BOND #
CERTIFICATE OF ADDRESS:�
INSURANCE pHONE dv'
PERMIT TYPE I ��GLE FAMILY
TYPE OF WORK: I� NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
�LREPLACEMENT
CITY
FAX
❑ TOWNHOUSE
Permit No`•C,
Received By:
Date Rec'd:
EXP DATE
EXP DATE
�_STATE_�ZIP � 2
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 ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($IS)
_ 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 that the inforrr►ation 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 perrr►it on site; that the work will be in accordance
with the approved plan in the �'�r 11 which e uireS review and approva�l� f lans//� /
SIGNATURE OF APPLICANT �%' IF� ��� � % PRI T ME iV /%� �'� DATE ( :
APPROVAL INSPECTORS SIGNATURE �7A,/,L�� DATE
l�' .
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977