P - 50474Building PLUMBING Permit No.�� � w��
Inspections RESIDENTIAL APPLICATION Received By:��Y
763-572-3604 CITY OF FRIDLEY �#���AY � � ���
763-502-4977 FAX EFFECTIVE 7-1-2010
DATET '
SITE ADDRESS �
THIS APPUCANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICAT'E OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
❑ OWNER
NAME: �
ADDRESS:�ii��
PHONE:�_
NAME:
STATE LICEN E # I
STATE BOND # PC
ADDRESS:��
PHONE asa _
� SINGLE FAMILY
❑ NEW
YO R E-MAIL ADDRESS
� -r�r�
�CONTRACTOR
� '
�c�e Cree�7er CITY �=
1-- l i�U
firf? �`!'X1fleC�IQf15. �n:
►�a�� -PM
��� ��
� �'�''J� C `� CITY_
I.�"Li�U � FAX
� TWO FAMILY
�� REPLACEMENT
��
❑ TOWNHOUSE
DETAILED DESCRIPTION OF WORK r{-���^� �(',d ��'('���
_�
ATE��ZI P��o�
EXP DATE ��
EXP DATE � L � 3 � �
�
STATE�ZIP����
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 WATER PIP[NG
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
[ 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 ar�d codes of the City of Fridley and with the Minnesota Construction Codes; that 1 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 t case of all w•k which requires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME �('1(Yi� �1 n�lr_ I DATE U"Zl f�^ i 2
APPROVAL INSPECTORS SI A RE
City of Fridley
Building Inspections Department ,
6431 University Avenue NE, Fridley,l�N 55432
763-572-3604
FAX: 763-502-4977