P - 45395Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � r . 11
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMTT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MA[L ADDRESS
Q OWNER
�� i
NAME:
ADDRESS: CJTY
PHONE:
STATE LICENSE #
Permit No. �� ( �'� l�"(�
Rec�B � �' x
��� ��
Date Rec' d:
EXP DATE
STATE ZIP.
STATE BOND # EXP DATE
ADDRESS: � c�. F'�JL CITY �_�M-� STATE
PHONE l �� � 2. r �— �"� �t � � FAX
PERMIT TYPE �GLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: NEW ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK -1—rJ 5'��0,.( c�'l1,cJ n p� �� r t�� o,.� v.� L1 a.� �� �jf �t.�C'�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
_ 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 [RRIGATION
WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIi, PROCESSED
I hereby apply for a plumbing permit and I owledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and c s o City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applic ' r 't and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in th case � which require review and appro�f pl /
SIGNATURE OF APPLICANT PRINT NAME c� j�,,J ��e-�-'��� DATE 7(( � Z� l�
APPROVALINSPECTORSSIGNATUR� DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
PAX: 763-502-4977