P - 48194Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2012
nA� �v � �
SITE ADDRESS �
THIS APPLICANT IS
PROPERTY
OWNERi
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
II�ISURANCE
PERMIT TYPE
TYPE OF WORK:
DET.
�O C
❑ OWNER
YOUR E-MAIL ADDRESS
�ONTRACTOR
Permit No.
Recei��-t, U
Date Rec'd:
ADDRESS: CITY STATE ZIP
PHONE:
NAME: � �ny Z ` �'J/`�
STATE LICENSE #_ t/ [9 e�L (� C o� EXP DATE
STATE BOND # EXP DATE
ADDRESS� �. �7 .0 � i �./rl n Y� �7 � CiTY _ �'1�/� c� � U STAT61i'� '�7.i
PHONE��
�$�&LE FAMILY
❑ NEW
[ON QF WORIC _
❑ TWO FAMILY
�REPLACEMENT
.S '�" CX, �� �S �
FAX
❑ TOWNHOUSE
N �1�1 e 'C.�1'r. �G' Ct- ( J� !dL
°,� e �a� (�va s � e r
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
BATH'T[JB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTI-IES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER L LAUNDRY TRAY WATER HEATER (S35) FOR IRRIGATION
WATER METER OTFIER
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 er it a d work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case of all wor1 vhic reyuires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME DATE
APPROVAL INSPECTORS SIGNATURE DATE _
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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