P - 45383�����
Building PLUMBING Permit Ne�
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY UF FRIDLEY Date Rec'd:
763-502-4977 FAX �FEC� i-i-zo� i -
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
❑ OWNER �CONTRACTOR
NAME:
PHONE:
STATE LICENSE #.
STATE BOND # f
SINGLE FAMILY
TYPE OF WORK: I � �W
❑ TWO FAMILY
,
�REPLACEMENT
CITY STATE ZIP
s ii s `. �
EXP DATE
EXP DATE
CIT'Y
FAX
❑ TOWNHOUSE
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVI�. MINIMUM FEE
$35.50.
� BATH SINK/LAV _FLOOR DRAINS _ SHOWER _ WATER PIPING
Z BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK Z WATER CLOSET BACKFLOW PREV. (S15)
1 DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IItRIGATION
WATER METER OTf�R
Number of fixttues @ S 10.00 � x$10.00 =$��
Number of fixttues @ $15.00 x $15.00 = $
Number of fixtures Q$35.00 x$35.00 =$
State Surcharge $ 5.00
(14IINIMUM 540.00) Tota1= $ � �
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL 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
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Consttuction Codes; that I understand this is
not a permit but only an applicarion 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,�se of all or hic e �res rev w/� d appro�f lans+� / �p, _�;
SIGNATURE OF APPLICANT _ _. `�.�L+'" �/� _ /��'I' NAMF+ J j � � J / {"i hS� � CiY�-' DATE `
SEP
` City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
�