P - 39645Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-i-201I
DATE (l_ /'��) I
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
S!-���
� OWNER
�t� 3l
Permit No.:
Received By:
Date Rec'd:
YOUR E-MAIL ADDRESS 5�...., ��} ( j� �, �(�O(}�'S �`/� h(y� (`p ��
L4.`CONTRACTOR
NAME:
AbDRESS: CITY STATE ZIP
PHONE:
CONTRACTOR NAME: i�i ?C ,j� (� ��'1��y°-�-7 ��t �M `�'' V��' J ��
SUB OUR STOA E OF STATE LICENSE # ��U �/ I� �i
LICENSE, BOND AND STATE BOND � �� �� �c/ 7%a
CERTIFICATEOF ADDRESS: �)�`�? �O/_ 5� y'�lcQ�' CtTY�i
INSURANCE pHONE �Q (����, I(l��p � FAX
PERMIT TYPE
TYPE OF WORK:
�SINGLE FAMILY
C�NEW
DETAILED DESCR[PTION OF WORK
D TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
EXP DATE
EXPDATE
ATEn,n. ZIPSS %/
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM fEE
�$3 .50.
BATH SINK/LAV 1FLOOR DRAINS SHOWER � WATER PIPING
� BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
,�CLOTHES WASHER � K(TCHEN S1NK � WATER CLOSET BACKFLOW PREV. ($IS)
� DISHWASHER LAUNDRY TRAY �WATER HEATER ($35) FOR (RRIGATION
_ WATER METER _ OTHER
TH[S 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 Ci of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and o is n t to start without a permit on site; that the work will be in accordance
with the approved plan in case f all ork w ch requir re �iew and approval ofp �lan
SIGNATURE OF APPLICAN �t ' T N ME -J �E' %7�(� ��/VYII /�� DATE
APPROVAL INSPECTORSSI ATURE DATE , ,
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977