P - 46510Building
Inspections
763-572-3604
763-502-4977 FAX
DATE `�
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE'
LICENSE, BOND AND
CERTIFTCATE OF
INSURANCE
PERMIT TYPE
�E oF wo�:
' 1\/ � I\ !'
Permit No.: �b� (/� 2 5`7 (p
RE SIDENTIAL APPLICATION Received By: /��✓
CITY OF FRIDLEY 'i��: � � ����
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS �� �i� ih 1�1 l�bJ w rn�!!w"1 • i1P��
O �a I,c �P,�.a �-� Vl �_
❑ OWNER �-�COi
NAME:
.a,nnxESS: k
PHONE: ��Q :7 :�I' �J4 �
rraME: b�i �� �
STATE LICENSE #
�i
EXP DATE
���
STATE BOND # EXP DATE
ADDRESS: �D� 1'[�l�(1�1'I.OVI�" S�' Y��:. CITY �F'f��ile�Ul STATE J�I'2 ZIP
PHONE ~T{�1 �J �G' � 7�iC� FAX
B SINGLE FAMILY
NEW
DETAILED DESCRIPTION OF WORK
0 TWO FAMILY ❑ TOWNHOUSE
❑ REPLACEMENT
FEES ARE BASID ON $10.00 PER FIXTURE, EXCEPT WI�RE NOTED. FIXTURFS: (INDICATE TOTAL NUMBER OF EACH BII.OV1�: MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIlvIMING POOL WATER SOFTNER ($35)
CLOTf�S WASHER KITCHEN SiNK WATER CLOSET BACKFLOW PREV. (S15)
_ DISHWASHER _ LAUNDRY TRAY X 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 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 for a pernvt 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 all � requires review and app�Q��, Q€p �}-�,,,a
SIGNAT[JRE OF APPLICANT PRINT NAME s�rJ1(:�1. �� ,(XA DATE __( I�(C�/ I 1
APPROVAL INSPECI'ORS SIGNAT ne�
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX. 763-502-4977