P - 48216Building
Inspections
763-572-3604
763-502-4977 FAX
DaTE � o�/ a�
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMTT TYPE
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
JR E-MAIL ADDRESS /G Yl
lY1 1 �i
❑ OWNER
NAME: .� . _ ., _ . L�j"K
ADDRESS: �CJI-I � S- �,�/h � CTTY
PHONE: ��Q,3 � �O5 - SJ�,� -
Permit No.: z� (�'(�����
Received By: �
D��°�
STATE LICENSE # ��'xt I�-'I L�S � EXP DATE
STATE BOND # �� Le� EXP DATE
ADDRESS: 'rl n � � Cl (�� ['TTY ,ne �! �-
PHONE `��L �'J !7' ��j' � FAX �
C�INGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
<�
TYPE OF WORK: I� NEW
DETAILED DESCRIPTION OF WORK
L�R�PLACEMENT
l "
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
BATHTUB GAS PIPING (NEED CTTY LIC) SWIMMING POOL
CLOTHES WASHER KITCHEN SINK WATER CLOSET
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35)
WATER METER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
WATER PIPING
WATER SOFTNER ($35)
BACKFLOW PREV. ($15)
�FOR IItRIGATION
OTEIER
Gl
I 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 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 pertnit on site; that the work will be in accordance
with the approved plan in the� e of al ork which requires review and approval of plan
SIGNATURE OF APPLICANT /7( (:�-''�^ ,�� PRINT NAME L.Gt l.+-1?A. ��l Y1S Yn 6r� s DATE I�� ai- %- ��
APPROVAL INSPECTORS SI ATURE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977