P - 47344Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE '�`
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
_.�- l
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
JR E-MA'I"L A�DDRESS
�C'-P � /✓ .
❑ OWNER
NAME: l C�'r^r/�N ��Cve �
ADDRESS: O �! C ��=' �CIT'
�
PHONE: � �s � •- � � ` � � 2' Z-
.___ l� C_
Permit No.�
Received By:� ` `�`1)
��`�e��$�� �. � �� � �
STATE�ZIP S��j
STATE LICENSE # 'S� �P �/ EXP DATE � Z—�� il I
STATE BOND # EXP DATE
ADDRESS: �� �— � CITY �'y` v STATE�ZIP �S�a
PHONE �p i � `- � � L �� � FAX
TYPE OF WORK: I� NEW
FAMILY ❑ TWO FAMILY O TOWNHOUSE
DETAILED DESCRIPTION OF WORK
l!�
<'_
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. F[XTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MIN[MUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIP[NG
BATHTUB 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 and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordina codes e City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an a lication f a permit n work is not to start without a permit on site�that the work will be in accordance
with the approved plan in t e case of w k w' 'res review and appr lans. /. / L/�
SIGNATURE OF APPLICANT INT NAME `� �'7�' e� DATE c�J l/ �'
APPROVAL INSPECTORS SIGNA DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977