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
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