P - 36947Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011 _ �
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SITE ADDRESS _���r"�33 c
THIS APPLICANT IS:
PROPERTY
OWIVER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
NAME:
YOUR E-MAlL
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❑ OWNER �CONTRACTOR
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STATE LICENSE #- :i�Q-�
STATE BOND # j�/Z� ��j
ADDRESS:%�l(� ��
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❑ rrEw
FAMILY
DETAILED DESCRIPTION OF WORK
Permit No.:
Received B
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� �/�'� EXP DATE �oZ "3l� O�p/'''i.
' E/XP''DATE /%"� /'"�O/r
!� CITY ( � � {�iq? STATF,��ZIP�,[
�' F� �S`�- � YYd' �G � � �
❑ TWO FAMILY ❑ TOWNHQUSE
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVi�. MIIVIMIJM FEE
$35.50.
BATH SINKlLAV FLOOR DRAINS SHOWER WAT$R PIPING
�Y BATHTtIB � GAS PIPING (NEED CITY LIC) SWIMMI1riG �'OOL WATER SOFfNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. (S15)
_ DISHWASHER � LAUNDRY TRAY _WATER HEATER ($35) FOR IRRIGATION
_ WATER METER ` OTI-IER
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Nu�nb�r of � (�a7 $I�.� . $10.0U = $ : � :
�. � � �: . � �.� �
Number of fnchues @ $1S.UQ x $15.00 = $
Number of $xtures @ $35.00 x $35.00 = $
State Surcharge $ 5.00
t1VIIiVIMUM 540.00) Tota1= � "V `-�
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing pe ' and I ackno led that the information above is complete and accurate; that the work will be in
conformance with the ordinanc codes of ' of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an appli for a pe ' d work is not to start without a permit on s' ; t the work will be in accordance
with the approved pl 1 w ires review and appr a of plan ������
SIGNATCTRE OF APPLICA PRINT NAME O � DATE %' �
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridiey, MN 55432
763-572-3604
FAX: 763-502-4977