P - 47788Building �������
Inspections �+ S��l�T�'IA� AP�LIC'��'ION ,
763-572-3604 �,�,�,� o� F����+ �
763-502-4977 FAX
, EFFECTIVE 1-1-2011
SITE ADDRESS �
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
_ PERMIT TYPE
YOUR E—MAIL ADDRESS
�k �lu�{ ,�1�
❑ OWN�R �CONTRACTOR
NAME:�
ADDRESS:
STATE LICENSE
STATEBOND#
ADDRE
PHONE
TYPE OF WORK: I� NEW
EXP DATE
Permit No.:
Received By:
Dat��d:�
A'
LE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
DETAILED DESCRIPTION OF WORK
L,YREPLACEMENT
� �
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICAT� TOTAL NUMBER OF EACH BELOW). NIINIMiJM FEg
$35.50.
_BATHSINK/I.AV _FLOORDRAINS SHOWER
_ BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL — WATER PIPING
_ CLOTHES WASHER KITCHEN SINK — _ WATER SOFTNER ($35)
_ DISHWASHER LAUNDRY TRAY WATER CLOSET _ BACKFLOW PREV. ($ IS)
— �WATER HEATER ($35) FOR IRRIGATION
e —
WATER METER OTI�R
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 perrnit but only an application for a pe 't a work is not to start without a permit on site; that the work will be in accordance
with the approved plan in t e se 'all �o k wh requires review and approva .ofp lans
SIGNATURE OF APPLICANT PRINT NAME J(�rC./� j/� DATE���6� _�/
APPROVAL INSPECTORS SIGNATURE I
L' �'ity oi ��-idley
�uilding �nspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
71