P - 36960Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�G i (�
SITE ADDRESS � 1
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
•rYrE oF wo�:
PLUM�iNG
RESIDENTI�L APPLICA'I'ION
CITY OF FRIDLE� i
EFFECTIVE 1-1-2�11
� ❑ OWNER
NAME: YI
ADDRESS: IO( b �
PFiONE:�
NAME:
STATE LICENSE #_
STATE BOND #
ADDRESS:��
PHONE �IO�-
�LSINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
YOUR E-MAIL ADDRESS
FAX,
❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
Permit No.:
Received By:
EXP DATE _
EXP DATE
TE�ZIP�2
Z
PEES 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 WATERPIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMNIING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN 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 LJNTIL PROCESSED
I 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 co es 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 rmit and w" is not to start without a permit on site; that the work will be in accordance
with the approved plan in t �se�,, f all��' jk hich r ires review and approvj� 1 o/� plan . �,,�,,���
SIGNATURE OF APPLICANT ����f/C� �" �,� PR�INT NAME X/! v{� Z�Q"!'f�7 DATE �"�
APPROVAL INSPECTORS SIGNATURE ��/.L(�/✓ l_ DATE _ i
� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977