P - 42107Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE J '- `
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:
0
❑ OWNER
YOUR E-MAIL ADDRESS
Permit No.: %��'0
�- - -. : ��
, .
['�.� �- y�� I
NAME:
ADDRESS: C►TY STATE ZiP
PHONE:
NAMt;: 1/ � �-- i �� r
S7ATE LICENSE #��� EXP DATE
STATE BOND # _ EXP DATE
PHONE �T�'3 �
�1JCiINGLE FAMILY O TWO FAMILY
�IREPLACEMENT
crn��
FAX
❑ TOWNHOUSE
/ ��/
ATE��ZIP�
i . ,
i � ! • ' • • • • � i/ � �' / � /�� � " �t � � / � i L/ - -
/ S
FEES ARE BASED ON $10.00 AER FIXTURE, EXCEPT WHERE NOTED. F1X't'URES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
�BATH SINK/LAV
BATHTUB
CLOTHES WASHER
� DISHWA3HER
I hereby apply for a pluml
conformance with the ordi
not a permit but only an a
with the approved plan in 1
SIGNATURE OF APPLICANTj
APPROVAL INSPECTORS 51
_FLOOR DRAINS
GAS PIPING (NEED CITY LIC)
� KITCHEN SINK
� LAUNDRY TRAY
SHOWER
SWIMMING POOL
� WATER CLOSET
,LWATER HEATER ($35)
_ WATER METER
� WATER PIPiNG
_ WATER SOFTNER ($35)
BACKFLOVJ PREV. (S15)
FOR IRRIGATION
_ OTHER
THIS IS AN APPLICA710N FOR A PERM[T-NOT VALID UNTIL PROCESSED
permit and I acknowledge that the information above is complete and accurate; that the work wili be in
es and codes of the ity of Fridley and with the Minnesota Construction Codes; that I understand this is
ation for a perm' d wor ' no to start w' out a permit o ite; that the work will be in accordance
I uDork r r� w anN a�Ippr v f� s E�� ��/
(
TURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977