P - 36939Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ��� I s�
S[TE ADDRESS G
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
�_Q S+c:ti /`�cr rKc�.� c
❑ OWNER bCONTRACTOR
ADDRESS: �O!% G e r'/�t CITY
PHONE: ! iD,3 - '�Y� - 9PrS'.�
Permit No::
Received By:�_
D���'�PR 1 � 2� 1
TATE ZIP.
STATE LICENSE # � Q 3S 3 EXP DATE
STATE BOND{ # D� �� �.@ EXP DATE
ADDRESS: i• D� QGt� �� 6 CITY��slc�/—' STATE�ZIP �,�D 1�
PHONE '? 6 3 "�/����-od 9� FAX �%%a 3-�4�/- 7� f' �
�INGLE FAMILY
'6�.NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
❑ REPLACEMENT
'{'R � � � o..n � •e
� TOWNHOUSE
\
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (1NDICATE TOTAL NUMBER OF EACH BELOW). MIN[MUM FEE
$35.SQ
_ BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
_ BATHTUB �GAS PIPiNG (NEED CITY LIC) _ SWIMMING POOL _ WATER SOFTTIER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
THIS [S 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 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 appiication 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 e o�ll work which requires review and approv� If�f pla�l .
SIGNATURE OF APPLICANT �/ 6.-----�' PRINT NAME /�"`.�r l%.a i`.. � DATE ��l.T- / �
APPROVAL INSPECTORS SIGNATURE T)ATR
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977