P - 42236Building
Inspections
763-572-3604
763-502-4977 FAX
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
DATE '' L ^ � C.1
SITE ADDRESS ��
THIS APPLICANT IS: ❑ OWNER
PROPERTY N�1E:
OWNER/ ,e,DDRESS:
TENANT
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
STATE LICENSE #_S�
STATE BOND {� � �.— I
ADDRESS:
PHONE �
TIGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
YOUR E-MAIL ADDRESS
❑ TWO FAMILY
�REPLACEMENT
r
Permit No.:��' � '�
Re� B�
Date Rec'd:
CITY
Git c- .
EXP DATE
FAX
❑ TOWNHOUSE
ATE ZIP
EXP DATE
�_STATF✓�,_ZI��
-- �
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BEIAW). MINIMUM FEE
$ .50.
� BATH SINK%LAV l' FLOOR DRAINS SHOWER I WATER PIPING
�BATHTUB � GAS PIPING (NEED CITY LIC) SW7MMING POOL _ WATER SOFTNER {$35)
CLATHES WASHER � KITCHEN SINK �WATER CLOSET BACKFLOW PREV. ($15}
� DISHWASHER � LAUNDRY TRAY _WATER HEATER ($35) FOR TRRIGATION
_ WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LJNTIL 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 applicat' for a pe it work is not to start without a permit on site; that the work will be in accordance
with the approved plan in th ase. f all wo w requires review and appro 1 of pl / �q
SIGNATURE OF APPLICANT PRINT NAME J�/L�%7yL�t•✓1 DATE �/ ���' ��
APPROVAL INSPECTORS SIGNATURE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977