P - 45310Building
Inspections
763-572-3604
763-502-4977 FAX
DATE / <o�`<�
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
PHONE:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
; 0�,� ��`.�u,�`
❑ OWNER �CONTRACTOR
CONTRACTOR NAME: � T Grd,�!
SUBMIT A COPY OF STATE LICENSE # O� l�/� � �
YOUR STATE
LICENSE, BOND AND STATE BOND # �/ �%�%�-
CERTIFICATEOF ADDRESS:�a��v Cfa�,(Jbi�%� // CITY!
1NSURANCE pHONE ��.�J -'��P�� ����i7 FAX
PERMIT TYPE I� SINGLE FAMILY
TYPE OF WORK: I � ��'
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNf�OUSE
� REPLACEMENT
Permit No. ��j d��
Received Byr�j ��
Da��"�'d� �... � ���
ATE ZIP_
EXP DATE �a-3/- �olo
EXP DATE ��-,3�- �D�O
� �% ����- STAT� ZIP ��
,. ri/1/�__ i� i ��;
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV�. MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
_ BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
_ CLOTHES WASHER _ KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HBATER ($35) FOR 1RRIGATION
_ WATER METER _ OTHER
Nurnber of fu�tures @$1 Ei.flU x$10.00 =$
Number of fia�tures @ $15.U0 x $15.00' = $
Number of fixtures @ $35.40 � x $35.i�0'= $ �5
State Surcharge ;. $ ' S.00
(MiNINiITM $40.00) Tota1= $ �� 8�
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing pernut 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 applicatio 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 ca o all w hi r uires review and approval of lans.
SIGNATURE OF APPLICANT Q�,�PRINT NAME �L� ��LT�. DATE 7�l �-II
APPROVAL INSPECTORS SIGNATURE DATE
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FQR BUILDING, ELECTRICAL AND MECHANiCAL WORK
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977