P - 44605Building
Inspections
763-572-3604
763-502-4977 FAX
DATE l2 � ��� I v
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:
�j
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
Permit No.: (�d� � � �
Received By:
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YOUR E-MAIL ADDRESS L� � SP r V) c.w � S �/"�.,5`�' . C�i .�✓J .
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❑ OWNER I�CONTRACTOR
NAME:
ADDRESS: CITY STATE ZIP
PHONE:
N�: h'► C �e � v� C �-J
STATE LICENSE # G y/ G% � n� EXP DATE � 2 �� %�
STATE BOND # � 3�a �� 9 EXP DA7"E
ADDRESS: � Z � 1� � �+ � �"! �� CITY � �/I t �'� STATE%rl�l! Z�s �/ �
PHONE `� � 3 7� a' O�So� FAX � y%"m��-
�Y�SINGLE FAMILY
r-
O NEW
DETAILED DESCRIPTION OF WORK
0 TWO FAMILY
❑ REPLACEMENT
�c. � ,- � �2ti �
, G w� � V�r �-t
❑ TOWNHOUSE
I/e��" l�Nt ��.P 2�- �l�
c' c-c��n �
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BEIAW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS � SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTf�S WASHER � KITCHEN SINK 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 LJNTIL PROCESSED
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 application f4 a perm' d work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the � o' 1 wo • vhich requires review and approv�a� p� s. /,� `
SIGNATURE OF APPLICANT �''�' PRINT NAME �-..�C7 '' ��(�� n"� DATE �� `jv // O
APPROVAL INSPECTORS SIGN RE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977