P - 46954Building ���J�g�N�
Inspections �5�DEN�'�A,L APPLIC��'I4N
763-572-3604 ��,�,� O�, ������T
763-5(i2-4977 FA�
EFFECT[VE 7-i-201 ]
vAT� li t i1
SITEADDRESS � �
THIS APPLICANT IS'
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
� ❑ OWNER
NAME: �'�Y
ADDRESS: �
;
PHONE:��,
NAM�
STATE LICENSE #_
STATE BOND #
ADDRESS: ���
PHONE �
fL] SINGLE FAMILY
TYPE OF WORK: I� NEW
DETAILED DESCRIPTION OF WORK
YOUR E-MAIL ADDRESS
❑ TWO FAMILY
�Ftl EPLACEMENT
CITY
FAX
❑ TOWNHOUSE
Permit No.:
Received B : ' ° � � �
���Rec�cC' ����
STA
EXP DATE
EXP DATE
STATF/✓{ ZIP,,�=t-��
T .
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 LTNTIL 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 c 1 wo� �hich reyuires review and approval Df lans/�� /
SIGNATURE OF APPLICANT � � �� f' - PRINT NAME � C�� �"�%7''� DATE /( /
APPROVAL INSPECTORS SIGNATURE � DATE
City of Fridley �
Building Inspections Department
6431 University Aven�te NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977