P - 35089Building
Inspections
763-572-3604
763-502-4977 FAX
DATE 1 ��EI
SITE ADDRESS �
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMTT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERNIIT TYPE
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE ]-1-20ll
YOUR E-MAIL ADDRESS
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❑ OWNER
NAME: ( .f j/1W
STATE LICENSE #
�SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
/�
TYPE OF WORK: , a NEW
DETAILED DESCRIPTION OF WORK
�ILEPLACEMENT
Permit N
Received By:
EXP DATE
,_
�� .� ,
A
EXP DATE
( STATE ZIP���Z
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATHSINK/LAV _FLOORDRAINS SHOWER WATERPIPING
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
I hereby apply far a plumbing permit and I acknowledge that the inforntation above is complete and accurate; that the work will be in
conformance with the ordinances and es of City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a it d work is not to start without a permit on site; that the work will be in accordance
with the approved plan in th e f 1 wo i requires review and approv��",� �f pl�/,�- /�,
SIGNATURE OF APPLICANT a PRINT NAME�1lVI�— a�`�7��� DATE 7��
APPROVAL INSPECTOIZS SIGNATURE / /YI �1 � _—DATE"'7 f
�`' City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977