P - 48217Building
Inspections
763-572-3604
763-502-4977 FAX
nn� i a o'� 7 L 1
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
Permit No.
RESIDENTIAL APPLICATION Receivecl By:�V�
CITY OF FRIDLEY ��f���; � � L8i
EFFECTIVE 7-1-2010
YOUR E-MAIL ADDRESS ��'x'✓'�-� ��/'j'L L%�.I^G�ii�il�CpNDILt�^�%�G �/1 O�
� .�-/'#-
❑ OWNER �C(
NAME: �►-
ADDRESS: r
PHONE: /U/3' � I '
NAME:��U�O V
STATE LICENSE #�!/GJ
STATE BOND # /�i"i �
ADDRESS: �� o'� E / vtLtll�1 � CITY�Q�
PHONE `''(� 3 � S� � `� �Gf'� FAX �
� SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
OF WORK
❑ REPLACEMENT
EXP DATE
EXP DATE
� �� STATE ZIP
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
�$ .50.
BATH SINK/LAV � FLOOR DRAINS l SHOWER WATER PIPING
_ BATHTUB _ GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK � WATER CLOSET BACKFLOW PREV. ($IS)
_ DISHWASHER _ LAUNDRY TRAY _WATER HEATER ($35) FOR IItRIGATION
_ WATER METER _ OTf�R
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
a
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 t e of ally �k which requires review and app y�1 of plan
SIGNATURE OF APPLICANT% M�-�- �tr.(�, PRINT NAME �U G�. �,(�'2G l m n. f DATE �� 7 ��
APPROVAL INSPECTORS SI ATURE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977