P - 42163Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE J � (
SITE ADDRESS
THIS APPLICANT [S:
PROPERTY
OWNER/
TENANT
YOUR E-MAIL ADDRESS
���`� r
OWNER t7CONTRACTOR
NAMh: / ^ V ✓' � [� ,/ / �
ADDRESS: d% / (/ Gj�
PHONE:
Permit No
Received By:
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE STATE LICENSE # EXP DATE
LICENSE, BOND AND STATE BOND # EXP DATE
CERTIFICATE OF ADDRESS: CITY
INSURANCE
PHONE FAX
PERMIT TYPE GLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK
STA
�
TATE ZIP
FEES ARE BASED ON $10.00 PER FTXTURE, 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 PERM[T-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 ordinanc d des of the 'ty f Fridley and with the ' nesota Construction Codes; that I understand this is
not a permit but on(y an a ion r or ' not to start with �per 't s' e• at the �c�y� be 'n accor ance
with the approved plan in of ll ' e review and appr a,�/qlf s, � �� �D �
SIGNATURE OF APPLICANT � PRINT NAME ��� DATE
APPROVAL INSPECTORS SI NATURE neTF iY �
`� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977