P - 47946Building PLUMBING Pei-rr►it rto.: 2,�j
Inspections RESIDENTIAL APPLICATION Received By: ''/ _
763-572-3604 CITY OF FRIDLEY p� �°- �
763-502-4977 FAX EFFECTIVE I-1-2011 1�� ������
DATE�SITE ADDRES _
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
�_ YOUR E-MAIL ADDRESS
��� ���
❑ OWNER L9EONTRACTOR
NAM .
ADDRESS: CfTY
PHONE:
NAME
STATE L10E SE #
STATE BOND # � _ � _
PHONE��
B'�INGLE FAMILY
❑ NEW
DETAILED DESCR[PTION OF WORK
. r.. ����.
� TWO FAMILY
P�'f�EPLACEMENT
FAX
❑ TOWNHOUSE
STATEy�`�_ / � Z
EXP DATE
EXP DATE
'Y/rGd /�1S�['ATE ���2�
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 DRA(NS SHOWER WATER PIPING
_ BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
_CLOTHES WASHER _ KITCHEN S1NK WATER CLOSET BACKFLOW PREV. ($IS)
_ DISHWASHER _ LAUNDRY TRAY ZWATER HEATER ($35) FOR IRR[GATION
_ WATER METER OTHER
TH[S [S AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the information above is comp(ete and accurate; that the work will be in
conformance with the ordinances and cod of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applic ' n permit w k' not to start without a p it on site; that the work will be in accordance
with the approved plan in t case work c r u' review and approva f lans. �
SIGNATURE OF APPLICANT PRINT NAME DATE 'Z-- //
APPROVALINSPECTORSSIG UR DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977