P - 84375Building
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
CERTIFICATE OF
INSURANCE
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
YOUR
❑ OWNER
•.' l�l%f'�l�l/,�i11�
•��' � /
� �A► . i / �
Permit No.��
Received By
2
ATE ZI P�a'd
STATE LICENSE # ����Gj �p/� EXP DATE _( .� �, �
STATE BOND # QDrf�.�n�l;onne�tians Inc EXP DATE
nD�t�ss: 12AS0 �h�ctnut RIvr�ITY STATE ZIP.
PHONE FAX
PERM[T TYPE I.�SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW �EPLACEMENT
DETAILED DESCRIPTION OF WORK
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). M[N[MUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOPTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
� DISHWASHER _ LAUNDRY TRAY _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 a no led e that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of t City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit d ork is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case o%all work•whic quires r view and apprqval of plans. il ,� �� j j�l
SIGNATURE OF APPLICANT P INT NAME � ; p� � ��/,�Jj DATE W!��_�
APPROVAL INSPECTORS SIGNATU '�-- '�—� T�—
City of Fridley
Bui'�ding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977