P - 42104Building
Inspections
763-572-3604
763-502-4977 FAX
DATE� VI
SITE ADDRESS �
THIS APPLICANT IS:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-Z011
❑ OWNER
YOUR E-MAIL ADDRESS
PROPERTY NAME: � (�G
OWNER/ ADDRESS: �" �I.� CITY
TENANT pHONE: �f � J' /��' 7�( Z� q
CONTRACTOR NAME: fL� v�t�
SUBMIT A COPY OF STATE LICENSE #
YOUR STATE
LICENSE, BOND AND STATE BOND #
CERTIFICATE OF ADDRESS:�
INSURANCE pHONE �12 ;/ '
PERMI'T TYPE
�rYrE oF woxx:
�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
�.�EPLACEMENT
�-
�
FAx _��
❑ TOWNHOUSE
Permit N
Received By: �V1Vf
Da,��?aMA1� 2 11
EXP DATE
EXP DATE
'1 STATE�_ZIP �
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) SWIMIvIING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. (S15)
_ DISHWASHER _ LAUNDRY TRAY zWATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTF�R
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL PROCESSED
I hereby apply for a plumbing permit a
conformance with the ordinances and c d
not a permit but only an application for a
with the approved plan in tl� s� all �
SIGNATURE OF APPLICANT !i
APPROVAL INSPECTORS SIGNATURE
�dge that the information above is complete and accurate; that the work will be in
`i�`y of Fridley and with the Minnesota Construction Codes; that I understand this is
� work is not to start without a permit on site; that the work will be in accordan
requires review and approv��-1 of pl
PRINT NAME �E[ /,�- �f �-�y DATE �
�.✓1 DATE
�'��� City of Fridley �
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977