P - 39991Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY 4F FRIDLEY
763-502-4977 FAX EFFECTNE 1-1-2011
DATE � J <<
SITE ADDRESS _�
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
YOUR E-MAIL ADDRESS
' � ,,,f � tt/� ,��; �
❑ OWNER NTRACTOR
NAME: `�G�t '��� i � �\Y G (n � �
ADDRESS: � �c 4 A��- w `
PHONE: � Ce� -� � �- � I SS% '�-.
STATE LICENSE # V
STATE BOND #
ADDRESS: ��.�
PHONE � �Z�
�A'SrINGLE FAMILY
�A
TYPE OF WORK: I� NEW
DETAILED DESCRIPTION OF WORK
� Ol.f�'L. �
� s- — cr�i
❑ TWO FAMILY
�EPLACEMENT
� �e` � (" �-�i � �L.G��
Permit No.:
Received By:� �
Dat�' iE�C��ti: � � � e� ! �
CITY - ^ � �STATE ZIP
U EXP DATE
EXP DATE
_CITY � �ia
_ FAX
❑ TOWNHOUSE
r,.? eL'W � r.1 u, i c,..
ATE��%LIP�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXNRES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50. ,
_ BATH SINK/LAV _FLOOR DRAINS SHOWER �ATER 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 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 City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permi d work is not to start without a permit on site; that the work will be in accord ce
with the approved plan in the c of all or re ' s view and approva of plansr �
SIGNATURE OF APPLICANT RINT NAME �,(� 1 I� � k'C.�C DATE
APPROVALINSPECTORSSIGN TURE � � DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977