P - 45748Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �P �
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:
�AILED D
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
�U��
❑ OWNER
NAME: �
1:��77.7�I.Y.�
PHONE:
NAME: V �c /1 �
STATE LICENSE #_
STATE BOND #�
ADDRESS: S`/
PHONE �
L�SINGLE FAMILY
(`
❑ NEW
N OF WORK
�-fZ, L��
R E-MA[L
❑ TWO FAMILY
❑ REPLACEMENT
Permit No.:� �
Received By: 1
Da���°�uN 3 2��
CITY
EXP DATE
CiTY �
FAX
❑ TOWNHOUSE
STATE ZIP,
EXP DATE
% �� STATE ZIP �S�O%
�
(
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EA BELOW). MIN UM FEE X
$ 50. � �l S��°��° r
�•BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
T BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER � KITCHEN SINK / WATER CLOSET BACKFLOW PREV. ($15)
� DISHWASHER _ LAUNDRY TRAY _WATER HEATER ($35) FOR [RRI �TION
, _ WATER METER I.OTHER �� �Q s� �
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 permit and work is not to start without a permit on site; that the work will be in accordance
with the a roved lan in the of a 1 or j�� h re uires review and a r al of la � / /
SIGNATU E OF APPLICANT �lL+ ���,,�J�-� � PR1NT NAM E�y/�//^ � UA � �I � DATE [� ` ��%� %/
APPROVAL INSPECTORS SIGNATURE DATE �
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977