P - 44944Building
Inspections
763-572-36U4
763-502-497? FAX
S1TE ADDRESS �
7'H15 APPLICANT LS:
PROPERTY
OWNER!
TENANT
SUBMIT A COPY OF
YOUR STATE
LICENSE, HOND AND
CERT(FICATE OF
RYSt3RANCE
PERMIT TYPE
TYPE OF WORK:
PLUIVIBING
RESIDENTIAL AP°PLICATION
CITY O►F FRIDLEY
�FSCT�vE �-�-aoio
YOL'R E-MAIL ADDRESS
❑ OWNER OCONTRACTOR
STATE tICENSE # -
S7ATE BOND #
ADDRES��• ry� �
PHONE " I �/l � �
�SINGLE FAMILY
❑ NEW
D8TAII.ED DESCRIP'170N OF WORK
❑ TWO FAMILY
�PLACEMENT
Pertnit No. t-�/� v UGIU
Received By:
Date R�; �1t � � �% Q c? � � �
'" F.'XP DA7'B `�
'� E'X�P DATE
ClTY __ ���l�� 3
— FAX �+ (G�-- g��-""
Q TOWNHOUSE
FEE3ARE BASED ON 510.00 PER FIXIURE, EXCEPT WHERE, AtOTED. PIXTURES: (1NDlCATETDTAL KtfMBER OF EACH 9ELd11�. MINIMUM FEE
535.50. I
BA'fH S[NKlLAV fLOOR pRAfNS SkI�WER r WATER PIPING �V
_ BATHTUB _ GAS P[P[NG (NEED CITY LIC) � SWlMMiNG POOL WATER SOFTNER (S35)
� CLOTHES WAS}iER KITCHEN S1NK T WATER CLO5ET _ gqC((�7„Q�y p�y, (g��
,,,^ DISHWASHER _ LAifNDRY TRAY ^W'ATER HFATER ($3S) FOR IRRIGATIQN
_ WAT6R [dETER � OTfiER
THIS I5 AN APPLICA'i74N FOii A PERMIT-NOT VAL1D UNTlL PROCE3SEII
i hereby apply for a plumbing permit and I acknowledge that the inforrnation above is completo and accurate; that the work will be in
confonnance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a perrtiit but only an ap L' ation for a ermit and wnrk is not W start without a permit on site; that the work will be in accordance
with tlse approved plan in c I rk whi r quires review and app of lans. // r�
SIGAiA71JRE OF APPLICANT �' PRINT NAMEa, ����I�qTE //�( �I�
APPROVAL IA[SPECTORS N TURE
City of Fridley
Building Inspections Department
6431 Universiry Avenue NE, Fridley, MN 55432
763-572-3604
F'AX: 763-502-4977
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