Loading...
P - 36740Building PLUMBING Inspections RESIDENTIAL APPLICATION 763-572-3604 CITY OF FRIDLEY 763-502-4977 FAX EFFECTIVE 1-1-2011 �, . � . , . vnTE �►- — � SITE ADDRESS _ THIS APPLICANT IS: PROPERTY OWNER/ TENANT 0 YOUR E-MAIL ADDRESS ❑ OWNER `�ONTRACTOR ADDRESS: CONTRACTOR rJA�: (� }-� SUBMIT A COPY OF —`�'}+t- YOUR STATE STATE LICENSE #_ LICENSE, BOND AND STATE BOND #_ CERTIF'ICATE OF p�DRESS:_�� INSURANCE pHONE / /- . �] _ �Ti"""'— PERMIT TYPE �SINGLE FAMILY TYPE OF WORK: ���'�' DETAILED DESCRIPTION OF WORK 0 Permit No.�V4� Received By: � .�e �� � ��-1-- � r . STAT'E ZIP_ �"//7 �' � • ,r�1/G � �. � . ���� ��� i�<�!/� � y i 1[ � i � � ❑ TWO FAMILY ❑ TOWNHOUS6 �EPLACEMENT �^ �l, _ ; .. aG T � BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NO'FED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVI�. MINIMUM FEE BATH SINK/LAV _FLOOR DRAINS � BATHTUB GAS PTPING (NEED CITY LIC) CLOTHES WASHER KITCHEN SINK DISHWASHER LAUNDRY TRAY SHOWER SWIlvIMIIVG POOL WATER CLOSET WATER HEATER ($35) WATER METER WATER PIPING WATER SOFTNER ($35) ~BACKFLOW PREV. ($IS) ��FOR IItRIGATION OTI�R . . . ;. _.. , . .. .. .. � y ;�,�r�'��.'t3':r q���" T'�g c: �'�"��'+ , l�ttYmbcn' of fi�tes @$YO.UO � X S1U.W �$ 0� � , , . . �,z Number of fiactures @ �15.00 x $15.fl0 = $ Number of fixtures @ $35.00 x $35.00 = $ State Surcharge $ �.00 [�xrntuM sao.00� To�� ��? U i.�M � p.i' THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED I hereby apply for a plumbing permit and I acknowleclge 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 th case of a1 wo hich requires review and approval of pl s. J/ '/ SIGNATURE OF APPLICANT�I�� �4��_�v—��—� PRINT NAME Qf��_DATE `�' ��"�' '�/ APPROVAL INSPECTORS S GNAT[JRE naTF City of Fridley Building Inspections Department b431 University Avenue NE, Fridley, MN 55432 763-572-3604 FAX: 763-502-497'7 r�: i o�-���-�+y i i