P - 43624Building
Inspections
763-572-3604
763-502-4977 FAX
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APFLI�A.TION
��'�'�' OF FRID���'
EFFECTIVE 1-1-2011
❑ OWNER
NAME: r I
A�DRESS: �D„
PHONE: �3 -
NAME:
STATE LICENSE #_
STATEBOND#
ADDRESS: 2 `V
PHONE�_
�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
YOUR E-MAIL ADDRESS
❑ TWO FAMILY
�PLACEMENT
Permit No.:2� ���d�� l�
Received By: J
,
� ���
CITY 1 ti' STA
EXP DATE
FAX
❑ TOWNHOUSE
EXP DATE
� _ � _ STAT&�ZIP�
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)
GLOTF�S 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 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 th���;se�f al����k which requires review and approv Q,�plail�s..,,s�`A' DATE
SIGNATURE OF APPLICANT G1c. "dl PRINT NAME � 1(.l� �rr'1 v�- G«
APPROVAL INSPECTORS SIGNA � DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977