P - 62705Building
Inspections
763-572-3604
763-502-4977 FAX
DATE
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MAIL ADDRESS G1 � � � � `�
SITE ADDRESS � % �� � ���5�� �i
THIS APPLICANT IS: f�OWNER ❑CONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
�
Permit No.:2DG,2 S'd `J
Received By:
Date Rec'd: � l
� � 1�+� =i . � . L.c"J r�
ADDRESS: ���-4 �� ,�� ./V /i CITY YY ,'Gi /� l� STATE V�/�%ZIP � S y 2 I
PHONE: � I Z - �i �O ' �v S p �
NAME:
STATE LICENSE # EXP DATE
STATE BOND # EXP DATE
ADDRESS: CITY STATE ZIP
PHONE FAX
�INGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
❑ REPLACEMENT
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50. •� t
� BATH SINK/LAV _FLOOR DRAINS v SHOWER _ WATER PIPING
BATHTCTB 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) R IRRIGATI N
— _ WATER METER �OTHER W �,� ba�
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 applicati r a permit and work is not to start �vithout a permit on site; that the work will be in accordance
with the approved plan in the e o all hi equires review and approyal of lans. �/� � ��
SIGNATURE OF APPLICANT PRINT NAME l�} h�'� 0� {' �G� fC�"", DATE _
APPROVAL INSPECTORS SIG UR DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977