P - 45306Building PLUMBING
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECT[VE 1-1-2011
DATE V "" � Z"«
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:
n
ADDRESS: C!1 V � �
�
Et -MA1L ADDRESS
� �.
ACTOR
� �Cj
S � CITY
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Permit No.:
Received By:_
Date Rec' d: �
TATT� `^� v ZIP
STATE LICENSE # ' EXP DATE
STATE BOND # EXP DATE
ADDRESS: �� � CITY �ry1 �L�� dv�;�t. STATE�� ZIP
PHONE FAX
qYSINGLE FAM[LY
❑ NEw
� TWO FAMILY ❑ TOWNHOUSE
DETAILED DESCRIPTION OF WORK lRs- (��,�,� �u.5�.�,..�,�.-1 �� �� �"o �-� �� �. ��S�-� v�-�'
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$3,� �
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
_ BATHTUB GAS PIPING (NEED CITY LIC) S�JIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK i/�VATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR [RRIGATION
WATER METER OTHER
TH1S IS AN APPLICATION FOR A PERMIT-NOT VALID LINTIL 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 a permit and wo k is,A�t to start without a permit on site; that the work will be in accordance
with the approved plan in the c�e� ox-1 ich r reg�`r�°v�ew and approv�a-1 of lans.
SIGNATUREOFAPPLICANT "` � ��'� ���.' PR T AMB �/c:��,%�� ���'� DATE �`���Z `���
APPROVAL INSPECTORS � / '"3�� DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 � �� � /
FAX: 763-502-4977