P - 39779�
Building
Inspections
763-572-3604
763-502-497,7 F
llA'1'E_� 01/�
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SI'I'L ADDRL;SS _
T'tilS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUl3MIT A CQPY OF
YOUR STA`fE
LICI;NSE, BOND AND
CERTIFICATC OF
iNSU�NCr
PERiVI[T TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 2-19-09
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❑ OWNER
NAME: /Vl
AllDItESS: � 7Jy
PHONE: ��a " �
NAME: Pil/�
STATE LICENSE #_
STATI; BOND #
ADDRESS: 7 �oa
PHONE q,�a -
�SINGLE FAMILY
❑ NEW
UR MAIL ADD�R/E
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�ONTRACTOR
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❑ TWO FAIvl1LY
`�REPLACEMENT
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/�"�3r�Y�S
Permit No.:������`�
Received By: � '�v' ` _
���e�c� B 1� 2 � � �
Exr DA� 3 ! / 2.
XP DATE � -�% � � i
Cl`CY ���I�Q� /'� � STA"I'E
_ FAX �,�Va - gy/- �q6 7
❑ TOWNIIOUSE
� r f�, a ril � ,DDwer
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED, FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV�. MINIMUM FBE
$35.50.
BA'1'H SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATH'fUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTN�R ($35)
_ CLO'tEIES WASHER KITCHEN S1NK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY =WATER HEATER ($35) FOR IRRIGAT'ION
_ WATER METER _ OTHER
Number of fixtures @ $10.00 x $10.00 = $
Number of fi�ctures �a, $15.00 x $15.00 = $
Number of fixtures @ $35.00 � x $35.00 = $�
State Surcharge $ ��
M( INIiV1UM $35.50) Tota1= $ ��� �
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the information above is_ complete and accurate; that the work wil! 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 a ication for a e i d work is not to start without a permit on site; that the work will be in accordance
with the approved plan ' th se of work ' h requires review and appro of plans
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SiGNATURE OF APPL[CANT , PRINT NAME G�,f �r1 �W'n�� DATE �/�
PLEASE NOTE: SEPARATE PERMITS ARE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977