P - 44836Building PLUMBING
Inspections �SIDENTI�4.I, A�PPLICATION
763-572-3604 ��TY �F FI�D�E�'
763-502-4977 FAX EFFECTNE 1-]-2011
Da-rE � I
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
�WNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERNIIT TYPE
TYrE oF woxx:
❑ OWNER
NAME: �
ADDRESS:��
PHONE: tp� 2 "
NAME ___ ��
STATE LICENSE #_
STATE BOND #
ADDRESS:�
PHONE ��
�f$INGLE FAMILY
i�
❑ NEW
DETAILED DESCRIPTION OF WORK
YOUR E-MAIL ADDRESS
❑ TWO FAMILY
�REPLACEMENT
CITY
FAX
Permit No.:
Received By:
A'
EXP DATE
EXP DATE
�STATE ZIP 2-
�,_, .
❑ TOWNHOUSE ,
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF $ACH BELOW). MINIMUM FEE
$35.50.
BATHSINK/LAV _FLOORDRAINS SHOWER WATERPIl'ING
BATH1'UB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KTfCHEN SINK WATERCLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL PROCESSED
I hereby apply far 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 the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a pe 't and wor is not to start without a permit on site; that the work will be in accordance
with the approved plan in the ev all o wh' h req es review and appro a,�' lan�^f' "��
SIGNATURE OF APPLICANT RI T ME /�1�� vw����r DATE G f �
APPROVAL INSPECTORS SIGNA i �� '� DATE '
�/ City af Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977