P - 40236Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �'( � ( � —
SITE ADDRESS S �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMTT A COPY OF
YOURSTATE
LICENSB, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-i-2011
5� P'.er
Permit No.:
Recei�{��y
C( t�
Date Rec'd:
E-MAILADDRESS C��e � Pr� D�f .q�'I M/�J • C��
� OWNER ]$CONTRACTOR
NAME: �. I�.�c,n � Z. �$ �1 —
ADDRESS: CITY STATE Z1P
PHONE:
NAME: p �. ��_q '1 �� ,
STATE LICENSE # EXP DATE
STATE BOND # EXP DATE
ADDRESS:_ IC7-�F t� /-'�'•SS �5' . l�/��� 0��� CITY Co�"'� 1*ip.�3 STATE Mu ZIP 5���3
PHONE � l'Z- 5�l � r� I D�( � FAX--��
O SfNGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
�TWO FAMILY
[� REPLACEMENT
la�� / �p ,��,
❑ TOWNHOUSE '
�,� S�al�h c.o poe�- '�. �
FEES ARE BASEDON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50. �
BATH SINK/LAV FLOOR DRAINS SHOWER t/WATER PIPING
_ BATHTUB GAS PIP[NG (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
_CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($IS)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR [RRIGATION
_ WATER METER OTHER
THfS [S AN APPLfCATION 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 apptica�t'Qn for a pe t�and c is not to start without a permit on site; that the work will be in accordance
with the approved plan in the �se�of c�hicV •�q res review and approv I of plans,_, q `
SIGNATURE OF APPLICANT PRINT NAME ��� � e j�✓"'c1.� DATE l� ��' 1
APPROVAL[NSPECTORSSIG UR n/IiC ne-rc i.
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
�� S
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