P - 60292Building
Inspections
763-572-3604
763-502-4977 FAX
DATE
SITE ADDRESS �(
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
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECI'IVE 7-1-2010
YOUR E-MAIL ADDRESS
tiU JU �
❑
Tcl I n-� �a_e_. G•I C�
STATE LICENSE #
Permit No.:
Received By:
l�e��e� �
EXP DATE
A'
STATE BOND # v EXP DATE
ADDRESS: �U�_�� ?» � CITY h STAT� ZIP�
PHONE �� 3 �j%, S�$ � O FAX %(p � �rl� �f` � '�01
SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
❑ NEW
DETAILED DESCRII'TION OF WORK /��C-t. �-�^ !2P G�'-F `-
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 WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) 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
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 ridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application fo a pe it and w is not to start without a permit on site; that the work will be in accordance
with the approved plan in the c of all or wh' h ires review and apprQv,a�l of plans /, ' a� ��
SIGNATCTRE OF APPLICANT PRINT NAME L�tUl�`0� �/ ZS���UVl.�ATE �I I
APPROVAL INSPECTORS SI A RE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977