P - 48099Building
Inspections
763-572-3604
763-502-4977 F
DATE
S[7E ADDRE _�
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
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 i�%
❑ OWNER f�ONTRACTOR
ADDRESS: i 2 SO Lri P�sc- � CITY
PHONE: 7� 3 - �.�o� ^ %%�S�
NAME� ��a I'S ff%'1Z f�/l(5
STATE LICENSE #
Permit No.:1.V� r �'V' � J�
Received By: � {
Date���l: ii��� � �
EXP DATE
ATE /hIZZiP,
STATE BOND # O S�v S .3 EXP DATE a6 �I
ADDRES3: /���-� �S � �� CITY ��Q�C G�rorC STATE �'�Z1P SS'�G 9�
PHONE 7 ?G 3-�K�3'�`O('�J FAX
�SINGLE FAMiLY
O NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY O TOWNHOUSE
,.�� REPLACEMENT
�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELAW). MIN[MUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMiNG POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. (S15)
DISHWASHER LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
_ WATER METER �OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing pennit 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 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 �c Se,,,of al w rk which requires review and approval of pJ �a?s
SIGNATURE OF APPLICANT /i�+�f�` PRINT NAME� «k- ��R I S2.E�1/S.�Ci DATE �'s �
APPROVAL INSPECTORS SI N�T�E DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
�i