P - 36886Building
Inspections
763-572-3604
763-502-4977 FAX
SITE ADDRESS 1
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMiT TYPE
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-20ll
YOUR E-MAIL ADDRESS
ay G"r �
-T
❑ OWNER �ONTRACTOR
NAME: � 1 � u t
nDn�ss: � �r
PHONE: � �
NAME: r M�
STATE LICENSE #
STATE BON #
ADDRESS: �!- b'O � +'f ��
PHONE �1��� !�V(r�
�7 SINGLE FAMILY � TWO FAMILY
�rsrnE oF woRx: I � NEW
DETAILED DESCRIPTION OF WORK
�REPLACEMENT
CITY
Permit No.:
Received B}�
D���'�.�.
EXP DATE
❑ TOWNHOUSE
FEES pRE BASED ON $] 0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATHSINK/LAV _FLOORDRAINS SHOWER WATERPIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK ' WATERCLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID iJNTIL 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 t 'ty o Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and o� is not to start without a permit on site; that the work will be in accordance
with the approved plan in the of 11 w hich re es review and approv,j� lans./�� Q�
SIGNATURE OF APPLICANT P,RI�j T NAME /�L � l:-L�1�DATE O l �
APPROVAL INSPECTORS SIGNAT L�Ci� ' DATE / i
V City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977