P - 35113Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � -/ ��`
SITE ADDRESS �
THIS APPLICANT 1S:
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
EFFECTNE 1-1-2011
YOUR E-MAIL ADDRESS
`� S� N�
❑ OWNER ❑CONTRACTOR
Permit No.:L�� ( r
Received By:a I ��'
Dat��� d`� i*� L �. � � � �
NAME:�`��`C' ��{c�N52Y'
ADDRESS: C[TY Ff ���L� STATE ZIP
PHONE:
� o�
STATE LICENSE # 6� T✓' G 5
EXP DATE � �. - 31 " /oZ
STATE BOND # EXP DATE
ADDRESS: �� � �ve y � L � CITY N ew ���t9 µ'E °�TATE ✓h'� ZI� 2
PHONE �,� � G �G' B�G� � FAX
❑ SINGLE FAMILY
� NEW
DETAILED DESCRIPTION OF WORK
11Y1'WO FAMILY
YXKt.PLACEMENT
�Pl tic.e- /'..�c
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED.
$35.50.
BATH SMK/LAV _FLOOR DRAINS
BATHTUB GAS PIPING (NEED CITY LIC)
CLOTHES WASHER KITCHEN SINK
_ DISHWASHER _ LAUNDRY TRAY
❑ TOWNHOUSE
��" �i��-r
FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
SHOWER
SWIMMING POOL
WATER CLOSET
gWATER HEATER ($35)
_ WATER METER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
WATER PIPING
WATER SOFTNER (S35)
BACKFLOW PREV. ($!5)
FOR [RRIGATION
_ OTHER
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 ap lication for a permit and work is not to start without a permit on site; that the work wili be in accordance
with the approved plan in e of a wo hi e uires review and approval of plans. %
SIGNATURE OF AAPLICANT PRINT NAME C I� U"S ��!/ k ka'' �� DATE � V[ g���
APPROVALINSPECTORSSI NATURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977