P - 44831Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ^ � � �
SITE ADDRESS ���
TH]S APPLICANT IS:
PROPERTY Np
OWNER/
PLUMBING Permit No.:�UI � ��J
RESIDENTIAL APPLICATION Received By:�_
CITY OF FRIDLEY ����� - � �
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER �ONTRACTOR
TENANT ADDRESS: CITY,
PHONE: G � ' " � 1 �
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
STATE LICENSE # C)
STATE BOND # �
ADDRESS: ��
PHONE �7�0 � �� �
❑ SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
7 ! `r ! - ! r "�
�� 02� �-
�7��'Y ��%Li
7 � �d
❑ TWO FAMILY
�REPLACEMENT
17/EL/./' '3 / '
CITY /
FAX
❑ TOWiVHOUSE
ATE ZIP.
EXPDATE_����1� ���
EXP DATE
��r STATE�ZIP�
U t--
FEES ARE BASED ON $10.00 PER FIXT'tJRE, 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 CITY LIC) SWIMMING POOL WATER SOFTTIER ($35)
_ CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY _WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
THIS 1S AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumb' g p it and, nowledge that the information above is complete and accurate; that the work will be in
conformance with the ordihanc�Es d co J of e City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an pli,�at' n fo erm and work is not to start ' a per it on site; that the work will be in accordance
with the approved plan in cas ' f a w i r uires review and app o�I ans. _ 1
SIGNATURE OF APPLICANT r PRINT NAME GJ ''� DATE �� �
APPROVALINSPECTORSSI TURE � nnTF
" City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977