P - 44985Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � �~ � t �
S[TE ADDRESS �L� �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING Permit No�.�� �a5�
RESIDENTIAL APPLICATION R � a �
CITY OF FRIDLEY Da��� '�,
EFFECTTVE 1-1-2011
YO�JR E-MAI� ADDRESS I l� � Y��G �`a � h" 7 C�i1 �./% C:' ,(`'
�ay"�7� �L. ��� ,�i� � �� i .::�� �. p�"'e�' �,1 � �J' �: _�`�`;;" �
NAME:���
ADDRESS:��
PHONE �.,,��
NAME:
STA7E LICENSE #_
STATE BOND # _
ADDRESS:
PHONE
[�SiNGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑CONTRACTOR
Ci TWO FAMILY
�EPLACEMENT
£CITY_ �%/ ,[/ f� STATE/v'�ZIIi'� �%
EXP DATE
EXP DATE
CITY STATE ZIP
FAX
� TOWNHOUSE
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELAW). MINIMUM FEE
�$35 0.
ATH SINK/LAV FLOOR DRAINS SHOWER iJC WATER P(PING
�[BATHTUB _ GAS PIPING (NEED CITY L1C) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK � WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) � FOR IRRIGATION
WATER METER OTHER
THI3 IS AN APPLICATION FOR A PERMIT-NOT VAUD UNT1L 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 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 permit on site; that the work will be in accordance
with the approved plan in the case ork which requires review and appre,�,�l,of lans r�,,�j ���� Z�°L� ��
SIGNATURE OF APPLICANT _ �, �, � � PRINT NAMEe`'�����'? "�•,�/�f�.+✓ DATE 1 �C
APPROVAL INSPECTORS SIGNATURE ��;�
p��¢ DATE "N�� I
� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977