P - 42737Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 7-1-2010
DATE�� �T / �
SITE ADDRESS _/n�,� (� ,
THIS APPLICANT IS:
PROPERTY N,�E:
OWNER/ �D�
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PHONE:
ADDRESS
❑ OWNER C�"ONTRACTOR
� � 1 _ �i1 _ . �
NAME��
STATE LICENSE #,
STATE BOND #
❑ SINGLE FAMILY
O NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
❑ REPLACEMENT
Permit No.
Received By:
� ���: �
CITY
EXP DATE
EXP DATE
s�c Z '—
FAX
❑ TOWNHOUSE
ATE 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)
CLOTHES 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 cod �of t City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applicat' o pe rt d, or is not to start without a�p� mit on site; that the work will be in accordance
with the approved plan in the se wo w c e es review and approv��l �plans.% >
SIGNATURE OF APPLICANT PRINT NAMFp ����v/��f DATE �
APPROVAL INSPECTORS SIG A E
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977