P - 46275Building
Inspections
763-572-3604
763-502-4977 FAX
DATE CO' ( ( 1
SITE ADDRESS _
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
RESIDENTIA�.�.. APPLICATION
CITY �F FRIDLEY
EFFECTIVE 7-1-2010
YOi �R E-MAII, ADDRESS
❑ OWNER �CONTRACTOR
STATE LICENSE #
Permit No.:
Received By:
EXP DATE
AT�Z��a�
STATE BOND # *r v� i i v-r �v� EXP DATE
ADDRESS: CITY STATE ZIP
PHONE E�,�q�-��IN '�d��`c3 F�
� SINGLE FAMII.Y
❑ NEW
❑ TWO FAMILY ❑ TOWNHOUSE
t�REPLACEMENT
/`
DETAILED DESCRIPTION OF WORK CIJ���✓ �'�� ��P�'`� 1�^-'en^- �
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV�. MIAtIMUM FEE
$35.50.
BATH SINK/LAV _FLOOR DRAINS SHOWER _ WATER P1PING
gATHTCTB GAS PIPING (NEED C1TY LIC) SWIMMING POOL WATER SOFTNER (E35)
CLOTI�S WASHER KITCHEN S1NK WATER CLOSET _ BACKFLOW PREV. ($15)
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 permit and I
conformance with the ordinances and c6�gs
not a perniit but only an application for a�
with the approved plan in the c f all wo�
SIGNATURE OF APPLICANT
APPROVAL INSPECTORS SIG
that the information above is complete and accurate; that the work will be in
'Fridley and with the Minnesota Consiruction Codes; that I understand this is
k is not to start without a permit on site; that the work will be in accordance
res review and appr val of plans�/` y�� /`
rI./�IRfiaTTATATAL'_�%.4Y1iP�/"'71YIPiJP�TIATF I A��I�I/
City of Fridley
(�uilding Inspections Department
6431 University Avenue NE, Fridley, NIN 55432
763-572-3604
FAX: 763-502-4977
le 3����