P - 39356Building
Inspections
763-572-3604
763-502-4977 FAX
DATE V V \
SITE ADDRESS ��
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOLTR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
F,FFECTNE 7-1-2010
YOUR E-MAIL ADDRESS
❑ C'�F�VNER �CONTRACTOR
ADDRESS: ��: � CITY.
PHONE:1�Q�?-�Z I—�lE�-I � � -
STATE LICENSE #
Permit No.:
Received By
� t5►e '�
EXP DATE I Z'" � �
rr v � i i.,-t �v�
STATE BOND # __sg�� �Tn EXI' DAT'E
n,DDxESS: 3��n nndd Rd cITY
rxorrE Eagan, N!N 55123 F�
� SINGLE FAMII.Y
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWp FAMILY ❑ TOWNHOUSE
�`REPLACEMENT
ATE ZIP
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (II�IDICATE TOTAL NUMBER OF EACH BELOV�, MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER _ WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWINIIvIING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET _ BACKFLOW PREV. ($15)
DISHWASHER LAUNDRY TRAY =WATER HEATER ($35) FOR IlZRIGATION
— WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I c ledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes o t e�iry of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a pe ' an ork i not to start without a permit on site; that the work will be in accordance
with the approved plan in the case of a prc�aLof plans. 1
SIGNATURE OF APPLICANT NAME IC��- ��� �'!� DATE �"-?i� `\�
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
� � S �!�'8