P - 36959Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � '� / �
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY N,�:
OWNER/ aDD1tE;
TENANT
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERlVIlT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
��cT� �-i-ZOio
YOUR E-MAII. ADDRESS
❑ OWNER �ONTRACTOR
STATE LICENSE #
STATE BOND #
ADDRESS:�
PHONE
L�SINGLE FAMILY
O i•rEw
DETAILED DESCRIPTION OF WORK
Pernut No.
Received By:�_
Date Reldid;,�� .� � ��i � � � 0 � �
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FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WFIERE NOTED. FIXTURES: (INDICATE TOTAL NtJMMBEER OF EACH BELOV�. MIhIIM[JM FEE
$35.50.
BATH SINKILAV FLOOR DRAINS SFIOWER WATER PII'ING
BATHTUB GAS PIPING (NEED CTTY LIC) SWIIvIlvIIAIG POOL WATER SOFITIER (S35)
_ CLOTI�S WASHER KITCHEN SINK WATER CLOSET BACI�LOW PREV. (S15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER (S35) FOR IRRIGATION
_ WATER METER _ OTFIER
N�:untyer of �mu� � �15.00 x $35.UU = $
Number of iixtures (a7 $35.00 x $35.00 = $
State Surchazge $ 5.00 �
(ArIINll1+IUM 5�.081 Total. = $ �"� � ��
THIS IS AN APPLICATION FOR A PERMIT-NOT VAIdD iINTII.. PROCESSED
I hereby apply for a plumbing peimit 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 pernut and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the �f al ork hich requires review and appro of plans. Q,,�� �
SIGNATURE OF APPLICANT �j PRINT NAME ��G(/L. � c I"f'/1"1/'!� DATE�'� y�� / I
.nrn���•r rwrnrn�i.m�no m�wremrmn
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-49'7?