Loading...
P - 44967Building PLUMBING Inspections RESIDENTIAL APPLICATION 763-572-3604 CITY OF FRIDLEY 763-502-4977 FAX �FECTrvE i-i-ZOi i SITE ADDRESS THIS APPLICANjl' IS: D OWNER NAME: � nn�ss:� PHO�: 7� YOUR &MAIL ADDRESS - .�' vh � P �' �r �QCON'I'RACTOR d-�Q r l.t 5�-�1M�er p�t � r-7/..,. . � f L�G Permit No.:, Received By: /� Date �e� � �+� � SS�.� / CONTRA�."IbR ' ` ' NAME: SUBMIT A C�PY OF STATE LICIIVSE # �t'/Q �-�d � EXP DA7E YOUR ST�ATE LICENSE, BO�+ID AND STATE BOND # EXP DATE �y�' CERTIFICA'TE OF ,e,DDRESS: �oZ..3 L V� CiJCCTfY ��G Qj) STATE ' Z1P. INSURAIy10E i PHQNE 7�� �7I � D�S� FAX PERNIIT TYPE OF DETAILED �SINGLE FAMILY O TWO FAMILY � TOWNHOUSE ❑ NEW OF WORK ❑ REPLACEMENT 'L ,�� FEES ARE BAS�D ON $10.00 PER FIXTtJRE, EXCEPT WHERE NOTID. FtXTURES: (IIVDICATE TOTAL NUMBER OF EACH BELOV�. I►aNIMUM FEE $35.50. BATFI SIIVI�2AV FLOOR DRAINS SHOWER WATER PIPING BATHTUB '�, GAS PIPING {NEED C1TY LTC) SWIMM[NG P�L � WATER SOFINIIt (S35} CLOTf�S �VASHER � KITCHEN SINK WA1ER CLQSET SACKFLOW PREV. (�IS) _ DISHWAS��ER , LAUNDRY TRAY �WATER HEATER (S35) FOR IRRIGATION WATIIt METIIL O�FR Number of @�10.W x S10.W = S Number of Number of fi� State Surc�a�gc @$15.00 x$15.0(1=� @ $35.00 x $35.00 = $ S 5.� (�1TIIYIMiI14i 540.00) To�I = $ �.UO THIS IS AN APPLICATION FOR A PERM(T-NOT VALID UNTIL PROCESSED I hereby apply for a plumbing permit and I aclrnowledge that the information above is complete and accurate; that the work will be in conformance with the ordinances and codes o e C' f Fridley and with the Minnesota Construction Codes; that I understa.nd this is not a permit but only an applic,ation for a permi w rk is not to start without a permit on site; that the work wiIl be in accordance with the approved plan in the case of atI work whi re ires review and appmvai af plans. SIGNAT[JRE OF APPLICANT P NAME DATE APPROVAL INSPECfORS SIGNATURE DATE PLEASE NOTE: SEPARA'IE RE FOR BUILDING. ELECTRICAL AND AL WORK . City of Fridley Building Inspections Department 6431 University Avenue NE, Fridley, MN 55432 763-572-3604 FAX: 763-502-4977 11 ��