P - 48307Building
Inspections
763-572-3604
763-502-4977 FAX
DATE
SITE ADDRESS �
TfiIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
� OWNER
lQ
�
YOUR E-MAIL ADDRESS
CITY
Permit No.: (� �
Received By:
����d�� LU I
A
NAME: TCrr�� (�.�^c�rc.@C.tX^
STATE LICENSE # EXP DATE
STATE BOND # EXP DATE
ADDRESS: J'r0� �,MQ►17 $� CITY J'�no�Sac.. STATE�� �ZI�_
PHONE �E13-�%:�- �`�JO FAX �(Q3" J�Ia`��SSq
� SINGLE FAMILY
❑ NEW
❑ TWO FAMILY ❑ TOWNHOUSE
�EPLACEMENT
DETAILED DESCRIPTION OF WORK W'(��-QY' SbC;- Y1�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 IRRIGATION
WATER METER OTHER
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 approved plan in the case of �u�rk which r uires review and app-�r-o�val of lans.
SIGNATURE OF APPLICANT i' PRINT NAME:.1 p �Y1, � f'`C!� i�a^ DATE ,� s' 7�/�
APPROVAL INSPECTORS SIGN
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977