P - 48408Building PLUMBING Permit Ivo.: �(;�l L� '��Z(`) �
Inspections RESIDENTIAL APPLICATION Received BY:1�
763-572-3604 CITY OF FRIDLEY ��� �� `"" `�° " � `� "
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763-502-4977 FAX EFFECTIVE 7-I-2010 �
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SITE ADDRESS __,� L
THIS APPLICANT IS:
YOUR E-MAIL ADDRESS
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❑ OWNER �CONTRACTOR
PROPERTY __���
NAME:
OWNER/ ADDRESS,� y _
TENANT
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STATE���iZIP��_�,3
CONTRACTOR NAME: ��� j(,� Y1(�Q� �,�}l�'l r ��(�_'��1svc�
SUBMIT A COPY OF STATE LICENSE # ^ ^� �7 }�
YOUR STATE `d�! E+c. �% �� m EXP DATE �_�r� ��.
LICENSE, BOND AND STATE BOND # t� G
EXP DATE _ �a- �
CERTIFICATE OF ADDRESS ��� �j �� }� �-+-�'�../ �i�Y- CITY �GV•L,=i,t�_.f�__ STATE ,� p�ZIP
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PERMIT TYPE
TYPE OF WORK: I� NEW
FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
DETAILED DESCRIPTION OF WORK
�REPLACEMENT'
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: QNDICATE TOTAL NUMBER OF EACH BELOW). MWIMUM FEE
$35.50
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
_ BA'I'HTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL � WATER SOFTTVER ($35)
CLOTHES WASHER KITCHEN S[NK WATER CLOSET � BACKFLOW PREV. ($IS)
_ DISHW.ASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
WA"IF,R METER OTHER
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Number of fixtures @ $10.00 ��� � � X $10.00 �� $
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Number of fi�ctures @$15.00 ` x$ IS.00 =$
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Number of fixtures @$35.00 � x$35.00 =$���� j k
c*�+o c,,�mharge � � $ �5.00 � � � ���
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(MINIMUM $40.00) � � � Total ='$ � ;' � J; �,�.,,�
I�HIS IS AN APPLICA"I"ION FOR A PERMIT-NOT VALID UNTIL PROCESSED
1 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 permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case of a�l work wl�ich requires revie�u�d approwal of plans. _ � � �
SIGNATURF OF APPLICANT / � � __���,(� '`PiZ1NT NAM� , � �F�� � < " � �__DATE � �
APPROVAL WSPF.CTORS SIGNATURF, t, �' -��.->-. , ✓' �.F=^
PLEASE NOTE: SEPARATE PERMITS ' REOUIRED FOR BUILDING. EL;E�TRI ��- `� ;: ��a�� �' C WORK���;�`t:
City of Fridley
Building Inspections Department ,
6431 University Avenue NE, Fridley, 1�N 55432
763-572-3604
FAX: 763-502-4977