P - 42154i
�/y �3� �
Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-497� FAX
. EFFECTIVE 1-1-2011
DATE � Z-
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SIIBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
❑ OVVNER
�j
Permit No.�.� ,
Received By:___���
Date Rec'd: �5 � 7�
YQUR E-MAIL ADDRESS � ��N�`� � %tUL . ��`�/f
��
ADDRES$: '- 1 � �� ��� /L/� CITY_
PHONE:
NAME• �C (-fL,�7`�� DS �yy�
STATE LICENSE #
S�'ATE BOND #
ADDRESS: �� � ,/�I7J� � �%- CITY_
PHONE ,-/7 Z r- �%3_.�- ZS R C_ FAX
TYPE OF WORK: i� NEW
FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
'[ ��STA
EXP DATE
EXP DATE
STATE Z1P
��% � .- �c/ c1'/
� � � • � � • � • '�l[ _� �• r% ��/ / i/ _� � i /r 11�1
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (IND[CATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35,50.
X BATH SINK/LAV 1FLOOR DRAINS SHOWER WATER PIPING
,� BATHNB _ 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 a�jd I acknow[edge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and cddes of the ' of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but o,n[y an application r a pe 't an ork is not to start without a permit on site; that the work will be in accordance
with the approvec� plan in the case 'ch uires review and approv 1 of�lans. -� j �
SIGNATURE OF APPI;�CANT RI T NAME �Gx ���l,��,7� ATE �
APPROVALINSPECT URE _ DAT �;`
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763=572-3604
FAX: 763-502-4977