P - 45396Building
Inspections
763-572-3604
763-502-4977 FAX
DATE__�,J tA i
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
O WNER/
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 1-1-2011
YOUR E-MAIL ADDRESS
G'_, C' rc��fC f�
❑ OWNER �CONTRACTOR
Permit No.: �i ('� 1 ZG}c�
R�,,e' ed U:
:�.'
Da�'te�ec�d: �
NAME:
ADDRESS: CITY STATE ZIP
STATE LICENSE #
EXP DATE
STATE BOND # EXP DATE
ADDRESS: � C j �I �� CITY ..�.�Spw��� STATEM ZIP�O�(
PHONE C�Fj3� � �'/ '�7.5�_ FAX
SINGLE FAMILY
'�hFEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
❑ REPLACEMENT
�
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
_ BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL
CLOTHES WASHER KITCHEN SINK WATER CLOS�T
, DISHWASHER i LAUNDRY TRAY WATER HEATER ($35)
WATER METER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
WATER PIPING
WATER SOFTNER ($35)
� BACKFLOW PREV. ($15)
FOR [RRIGATION
_ OTHER
I hereby apply for a plumbing permit and I ckn wledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances an o s e City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applicati it and work is not to start without a permit on site; that the work witl be in accordance
with the approved plan in the s rk which requires review and appro p,la j / o�
SIGNATURE OF APPLICANT PRINT NAME 6cJ �F'�P C1u1/ICAJ�1 DATE 7��� —� e
APPROVAL INSPECTORS SIGN TU �ATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977