P - 44919Building
Inspectians
763-572-3604
763-502-4977 FAX
DATE +'j�:
S1TE ADQRESS �
THIS APPLICANT [S:
PROPERTY
OWNER/
TENANT
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PLRMIT'C'YPE
PLUMBING
RESIDENTIAL APPLICATION
CIT�c' QF FRIDLE�
EFFECTiVE 7•1-2010
� _ YOL'R
.+ '�1r1rG
❑OWNER �ONTR.q
NAME: II �
ADDRESS:� �r`�
PHONE:
NAME: t
STAT6 LICENSE # � n �
Permit
Received By:
EXP DATE
STATE BOND # EXP DA'fE
ADDRESS: _ �}' E �ln. ('trv ti11� STATE�_ZIP
PHONlE ""7� ;1- ,i��-t gSt�O ppX
TYPE OF WOIiK: I� NEW
FAMtLY ❑ TWp FAMILY O TOWNHOtJSE
DETAILED DESCRIPTiOAi OF WORK
�LACEMENT
� �
FEES ARE BASED ON S 20.00 PER FUCTl1R6, EXCEPT WHEAE NOTED. FIXTURES: (tNC11CA1'E TOTAL NUMBER OF EACH BE(,QLy), MIN1MLiM FEE
$35.50.
BATH SQIKlLAV _FLOOR DRAINS S}lOWER _ WATER PIPING
_ BATHTCJB _ GAS PIPII�G (AtEED CITY LIC) SWIMMiNG PUOL WA'CER SOFTNER (T�35}
_ CLUT1iES WASHER _ KITCHEN SLNK _ WATER C[,OSfiT � BACKFLOW PREV. ($IS)
_ DISHWASH.ER _ LAUNDRY TRAY WA'CER HEATER ($35) R lRRIGAT[QN
_ WATER METER pT[{ER �nn 1_ �� if�i
TH1S IS AN APPLICATION F�R A PERMIT-�•pT VALID UNTIL PROCESSED
I hereby apply for a plumbing pernut and I acknowledge that the infarmation above is complete and accurate; that the work w'sll be in
conforn�ance with the ordinances and cod�s..�f Ehe City of Fr' ley and with the Minuesota Construction Codes; that 1 understand this ss
not a pes7nit but only an application for a pe ' and wo � not to start without a permit on site; that the work will be in accordance
with the appr�oved plan in case of all w 'c e� es review and appr 1 of plans. [,-'�� �� I(
SIGNATUREaFAPPi.ICAiYT �AME �h�C..Kf&l � � DATE
APPROVAL /NSPECTORS SIG RE �
City of Fridley
uilding Inspections Department
$431 University Avenue NE, Fridiey, MN SS432
763-572-3b44
FAX: 763-502-A�977
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