P - 50482Building
Inspections
763-572-3604
763-502-4977 FAX
DA� S =Z -/Z
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:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR �MAIL ADDRESS
�tld /'Y, 0/L � Li
❑ OWNER [�ONTRACTOR
Permit No.:
Received
D�`Qe��c
ADDRESS: �,.+a,.c_ �S k'�Ii"'�/ CITY STATE ZIP,
PHONE: %(03 – Zv� �,��
STATE LICENSE
EXPDATE /Z "3�� I,i
STATE BOND # EX/P DATE
ADDRESS: ��I D� � �vf�r.vL. ��o „��CITY �S�'.�T-� STATE/_1�vaIP�
PHONE �% 3 ' �Sj ' (�U � Z FAX �'�'.''��
�SINGLE FAMILY
❑ NEW
DETAILED DESCRII'TION OF WORK
❑ TWO FAMILY � TOWNHOUSE
B'REPLACEMENT
FBES ARE BASED ON $]0.00 PER FIXNRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELQW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER _ WATER PIPING
gATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL _ WATER SOFTNER ($35)
CIATEIES WASHER KITCHEN SINK � WATER CLOSET _ BACKFLOW PREV. ($15)
DISHWASHER LAUNDRY TRAY _WATER HEATER ($35) FOR IItRIGATfON
— W ATER METER _ OTEIER
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 pe it and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case of a�l or requires review and approval p sr,� �_Z,��
SIGNATURE OF APPLICANT �J../ . PRINT NAME ,�'� llOr� DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977