P - 41738Building
Insp�ctions
763-572-3604
763-502-4977 FAX
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-201I
DATE ` �-(� YOUR E-MAIL ADDRESS
SITEADDRESS �3'7LI �c� ��J''Fb� A/� %��/I>�y Ol''I.�/ .�Syr�I
THIS APPLICANT IS: � OWNER �!(CONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
ADDRESS:
PHONE:
0
��
CITY
Permit No
Received By:
�� ��'���
ATr,s ts�ZIP��1
p� -- -- —
STATELICENSE# �%.�y! /'%`'% EXPDATE I�aZ "S�% ` ZO%Z
STATE BOND # ��`Q ���j JS� EXP DATE /�°z ^ 3% '- ZW �/
ADDRESS: �6 �jCJ /�)y2�,%� `!'' ,O%1 CITY�fi�jJ/�/,�/�'/7��N/�STATE /%J✓LIP_ <,'�`,�c �
PHONE �p 3 ^ ��%� ��jQ'% FAX
�---
INGLE FAMILY ❑ TWO FAMiLY ❑'T'OWNHOUSE
TYPE OF WORK: � � NEW �REpLACEMENT
DETAILED DESCR[PTION OF WORK ��f�1/�C� �9// �- 'Tb /C,C� � T(/,��I/ /°!�i !� 7a A SfiOk/�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MIN(MUM FEE
$35.50.
R BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
� BATHTUB _ GAS PIPING (NEED CITY LIC) SW[MMING POOL � WATER SOFT'NER ($35)
_ CLOTHES WASHER _ KITCHEN S1NK � WATER CLOSET BACKFLOW PREV. ($f5)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
_ WATER METER OTHER
THIS IS AN APPLICAT(ON 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
conforntance 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 applica ion for a permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in th e of all w�ch requires review and approv,„a,l� plans. .-- ., �y
SIGNATUREOFAPPLICANT �'Ie� PRINTNAME "'��Ll� Q '�DIZ/�C �"(��'�G��I
DATE
APPROVAL INSPECTORS. T11RR ... T..
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977