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Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CIT'� OF FRIDLE�
763-502-4977 FAX EFFECTIVE 1-1-2011
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DATE
SITE ADDRESS _
TI-IIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
� OWNER
ADDRESS
YO(JR E-MAIL ADDRESS
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RYGBidTRACTOR
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NAME:_ C��C,�"'� �` ��-��-'�X- (,�Vl/'liS}��"��CC1S-�W�' (/'�C..�
STATE LICENSE # C\�,i �j�ry � � -' ��'�'1 EXP DATE .i ^I � " � V j Z_
STATE BOND # + �. P(��`- ��"► C� EXP DATE Y��" Z�t � ��
ADDRESS: � 5 S t,,,� t��'�-- -�� �3�: 1� cI� �: c:. �'L�,r�--e; STATE�Yi_�} ZIP ��-(�
PHONE � ��-� �'i��— � �.C" � � FAX
TYPE OF WORK: f� NEW
FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
f�,1�LACEMENT
DETAILED DESCRIPTION OF WORK
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FEES ARE BASED ON $] 0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINKILAV FLOOR DRAINS SHOWER WATER PIPING
� BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
�_ fe�OTHES WASHER _ KITCHEN SINK � WATER CLOSET _ BACKFLOW PREV. ($15)
�! DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
_ WATER ME'TER _ OTHER
THIS IS AN APPLICATION FOI2 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 permit arad work is not to sta ithout a permit on site; that the work will be in accordance
with the approved plan in the case of a' _..-." :.� "' --evie an ap roval of plans. . ` 1�,... c� -�.F�; `
SIGNANREOFAPPLICANT p M �a �,�'_�����,t�-` DA� ��J �
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APPROVALINSPECTORSSIGNATURE DATE
City of Fridley
Building Inspectio�s Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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