P - 48133Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ��" !�' ! �
SITE ADDRESS �
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
[NSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MAIL ADDRESS
O OWNER '�ONTRACTOR
Permit No
Received By:
�. - • �"� ' �
-=��i`:�i � � �
NAME:_ �b �v�- � %2e vt e.< � °� �CZrO�%
ADDRESS: �S�-� %Z�'['L �/�,(C '��l1- CITY�-�i.:� �G�� STA
PHONE: %G3' S�S/- �90�
-- --- r- - i i2 �� /.-
STATE LlCENSE# �$'—j,��J', � f EXP DATE lo'f-3/-7�/
STATE BO1VD # EXP DATE
ADDRESS: `rr% �C.�L �jlp CiTY !��✓�� STAT���ZIPSTL� %(
PHONE Z � 7��%�/�/.�-- FAX
[�SINGLE FAMiLY
O NEW
'AILED DESCR[PTION�F WORK
rLc4��. �i,i3 n� Ti�.?.
O TWO FAMiLY ❑ TOWNHOUSE �
�PLACEMENT
�..�
fEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACN BELOW). MINlMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAfNS SHOWER
_ BATHTUB �GAS P(PING (NEED CITY LIC) SW(MMING POOL
CLOTHES WASHER KITCHEN SlNK WATER CLOSET
,� D[SHWASHER _ LAUNDRY TRAY WATER HEATER ($35)
WATER METER
TH[S [S AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
WATER PIPING
_ WATER SOFTNER (S35)
_ BACKFLOW PREV. (SIS)
FOR (RRIGATION
_ 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 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 th all work which requires review and approvai f plans.
SIGNATURE OF APPLICANT-�-�1�� �^ PRINT NAME ��`„�l'G�r� �t DATE %�%/�-�/
APPROVALINSPECTORSSIGNATURE ' DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
7b3-572-3604
FAX: 763-502-4977