P - 44946Building
Inspections
763-572-3604
763-502-4977 FAX
DATE i���
SITE ADDRESS '�'_
TfIIS APPLICANI' IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
DETAILED DESCRI
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
YOUR E-MAIL ADDRESS
O OWNF.,R
ADDRESS:
PHONE:
NAME:��twa'r1otN �j�M%I
STATE LICENSE�Q�psj�' 7 �
STATE BOND �1
Permit No.:
Received By: �
- l�r�.r. _ _ . .
ATE ZIP
EXP DATE _����a.(9IO
�b
EXP DATE
ADDRESS: r��,'���_�G /� CITY��� STATF�ZIP��
PHONE ��. 7.� I t N%� FAX
�SINGLE FAMII,Y
� NEW
OF WORK
❑ TWO FAMII.Y � TOWNHOUSE
�REPLACEMENT
FEE3 ARE BASED ON $10.00 PER FIXTURE,, EXCEPT WHII2E NOTED. FIXTURES: (1NDICATE TOTAL NUMBEI2 OF EACH $L�Lp�V}. ivIINIMtJM FEg
$35.50. � /
_ BATH SII�K/L,AV _FLOOR DRAINS SHOWER �� WATER PIPING
_ BA1'H7'UB 'GAS PiPING (NF,ED CITY LIC) SWA�TG POOL WATER SOFTNER ($35)
_ CLO'LI�S WASFiER KTI'CHEN SINK WATER CLOSET —
_ DISHWASHER _ LAUNDRY TRAY _WATER HEATER ($35� FOR IItRIOGA �V �$15)
_ WATER METER pT�g
�, . �
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID IJN7'IL PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; that the work will be in
conforrnance 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 the c�of a1 work which requires review and approval of plans. '/
SIGNATL.TRE OF APPLICANT PRIN1' NAME�_�� ,%'lt,y�nw,t,. DATE I I/ 9/�
APPROVAL INSPECTORS SIGN TURE �r---
City of Fridley
Bu-i�d�ng ��s��tio�s D�pa�t�e�t
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977