P - 48063Building
Inspections
763-572-3604
763-502-4977 FAX
DATE_�
SITE ADDRESS �
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
NAME: -
ADDRESS:
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
w�e7cx�1�
OWNER OCONTRACTOR
Permit No.
1
Received By:�
Dat�R�'d�
I�C�. �
ATE ZiP
STATE LICENSE # \ EXP DATE
STATE BOND # ?�' EXP DATE
ADDRESS: CITY STATE ZIP
PHONE J \) FAX
�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
❑ REPLACEMENT
FEES ARE BASED ON $10.00 PER FIXI'URE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED C[TY LIC) S WIMMING POOL WATER 30FTNER ($35)
CLOTHES 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 UNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; that the work wili 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 th c e of all work ich rerq.u' s rev�ew and approval of plans.
SIGNATURE OF APPLICANT __���iLL)'3n.C� �u PRINT NAME ��F'Cj/�'f e,��/�G�� DATE�� �""l��
APPROVALINSPECTORSSIG TURE V DATF. '
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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