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Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFEC�nvE �-i-zo>>
DATE�
SITE ADDRESS �C
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
YOUR E-MAIL ADDRESS /�
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❑ OWNER �C'ONTRACTOR
Permit N
Received By:
Date Rec'd:
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NAME:_t5d�•nu � ,c>hd�.So t�
ADDRESS: o�J'�' �?�2 � w« N� CITY �'_�;� STATE �^ZIP S S�/,�'
PHONE:_ 7�P .3 " Jc7�- �0 �
NAME: � �I� lc,cY+Z� �/t ��l t
STATE LICENSE # _ ��_p ��l�j I��'�I EXP DATE �' ' l�
STATE BOND # o� 3 S 3�. EXP DATE
ADDRESS: ��j S7�d` °C� id ✓� %�/'� V`C � CI �%r�`� G ro'vL STATE ^'l Jf ZtP S S^
PHONE �'J`�l .Z[CD �3l� FAX
TYPE OF WORK: I� NEW
FAMILY ❑ TWO FAMILY O TOWNHOUSE
�REPLACEMENT
DETAILED DESCRIPTION OF WORK �'/$�r% �t t•✓ t�*�'rr1�.'/' /YCaf�/: �!�lrlsy 2.ksS1�. �2 9'
CD.I/s% ��/1 dl�L�i G1/i �7. l�yde ��..�S.i �, /LL_ �-
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 DRAINS SHOWER � WATER PIPING
_ BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTTIER ($35)
_ CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($IS)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID iJNTIL 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 ' of Fr' 1 y and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and ork s ot to start without a permit on site; that the work will be in accordance
with the approved plan in the case of wo k hich re r view and a roval of lans. �
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SIGNATURE OF APPLICANT 1y,TjV�� �� �� JLna.i�cc � DATE f�^
APPROVAL INSPECTORS SIGNATiiR . //DL�.�" / r,eTC �� �,
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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