P - 48013Building
Inspections
763-572-3604
763-502-4977 FAX
DATE I Z�j " l �
StTE ADDRESS ,5'Z
TH(S 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 1-i-201I
❑ OWNER
ADDRESS:
PHONE:
YOUR F.�MAIL ADDRESS /]SP�L..
�(CONTRACTOR
CITY
Permit No.:
Received By:' I �JY
Dat���:��� � � � 1�
ATE_ZIP,
NAME: !� µ✓ G �
STATE LICENSE # Oli l'��i ���'-� EXP DATE 1 Z' �r� I Z�
STATE BOND #�9'o�a�f� , EXP DATE JZ� 3/ "( Z
ADDRESS: o� ��' iI �`% `��� . CITY Z/ �'�A�,.,p,•�.,,� � STATFIC.� ^ ZI P�,�
PHONE [v( � � �(sS � �Q ' f FAX % (�3 � FSS�o • v�di''1
PERMIT TYPE I �SINGLE FAMILY
TYPE OF WORK: I� NEW
DET I ED DESCR[PTION OF WORK
A�� Ra.. c;��,�
❑ TWO FAMILY
�REPLACEMENT
GO ,�i � -�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED.
$35.50.
BATH S1NK/LAV FLOOR DRAfN5
BATHTUB GAS PIPING (NEED C►TY LIC)
CLOTHES WASHER � KITCHEN S1NK
� D[SHWASHER _ LAUNDRY TRAY
� TOWNHOUSE
S%�
FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINfMUM FEE
SHOWER
SWIMMING POOL
_ WATER CLOSET
_WATER HEATER ($35)
_ WATER METER
TH[S [S AN APPLICATION fOR A PERMIT-NOT VALID UNTIL PROCESSED
WATER PIPING
WATER SOFTNER ($35)
BACKFLOW PREV. ($IS)
FOR IRR[GATION
� OTHER
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 t ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only a 'cation for a p t a rk is not to start without a permit on site; that the work will be in accordance
with the approved plan in the s tl wor ' h r uires review and apT�� I of p an C DATEI ��(
SIGNATURE OF APPUCANT PRINT NAMET a�. �� ��_ Z�
APPROVALINSPECTORS NATURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977