P - 44532Building
Inspections
763-572-3604
763-502-4977 FAX
DATE `1—
SITE ADDRESS J
THIS APPLICANT IS:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTI VE ] -1-2011 �
�l � �
■ • '
YOUR E-MAIL ADDRESS
Permit No.:
Received By:
PROPERTY NAME: ��P,�P n �C[`� rS �iVl,
��E� ADDRESS: CITY STATE
�Narrr �,%! — 2
PHONE: _
ZIP
SUBMIT A COPY OF �• , w< •
YOURSTATE STATELICENSE# P'ti9�i��" C;'T� i°d1,�i1�`��'iq'1!y �;*� EXPDATE
LICENSE, BOND AND STATE BOND # SZg� ��&il Sf_ N� i# �� EXP DATE
CERTIFICATE OF ADDRESS: FI'I�IP!/��� ��(�� CITY STATE ZIP
11vSURANCE rxoxE (763) 754-2199 Fax (7��) 7�t-2��1�nx
_ PERMIT TYPE
�rE oF woxx:
SINGLE FAMILY
� NEW
DETAILED DESCRIPT'ION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVi�. MINIMUM FEE
$35.50.
BATH SINK/LAV _FLOORDRAINS SHOWER WATERPIPING
BATHTiJB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATERCLOSET BACKFLOW PREV. ($15)
DISHWASHER LAUNDRY TRAY W R HEATER ($35) FOR IRRIGATION
ATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL PROCESSED
I hereby apply far a plumbing permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances a codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applicati f a permit d work is not to start without a ermit on site; that the work will be in accordance
with the approved plan in the c rk h r uires review and approval ans. �
SIGNATURE OF APPLICANT �`+ PRINT NAME DATE
APPROVAL INSPECTORS SIGNA,�YTIt� � ' DATE ,� 1
'' City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
'FAX: 763-502-4977